The nurse is discussing staff assignments. Which client assignment should be given to the nurse’s assistant?v
-
Solution
Answer B is correct. The client with the stroke is the most stable client of the ones listed. The client in answer A would need extensive assessment. Answer C involves a client with a need for psychosocial support and nursing interventions. The client in answer D is a new admission with an infected diverticulum and would be less stable, with more unknowns.
A client with pancreatic cancer has just been given a negative prognosis by the oncologist. The nurse hears the client state, “I don’t believe the doctor, and I think he has me confused with another patient.” This is an example of which of Kubler-Ross’ stages of dying?
-
Solution
Answer A is correct. Kubler Ross identified five stages of dying as the ways that people cope with death: denial, anger, bargaining, depression, and acceptance. Answer A is the first stage of denial that can be used as a buffer and a way to adapt. Other examples of statements made by the client in this stage are “This can’t be true” and “I want another opinion.” When dealing with these clients, the nurse needs to use openended statements, such as “Tell me more.” Answers B, C, and D are a few of the other stages of dying and, thus, are incorrect.
A client is 4 hours post-operative left brain cerebral aneurysm clipping. Which assessment finding would cause the nurse the most concern?
-
Solution
Answer C is correct. The assessment finding that causes the most concern is the finding that could indicate a possible stroke. The right-sided weakness would mean there is a loss of muscular functioning on the side opposite the surgical procedure. Answers A, B, and D might indicate a need for reassessments but not a cause for immediate concern or intervention, so they are incorrect.
The nurse is explaining about the drug zafirlukast (Accolate) to a client with asthma. Which comment by the client would indicate ineffective teaching?
-
Solution
Answer A is correct. Accolate should be taken 1 hour before or 2 hours after eating to prevent slow absorption of the drug caused by taking it with meals; therefore, this statement is incorrect and requires further teaching by the nurse. Answers B, C, and D are all true statements regarding this drug and are correct statements made by the client.
The nurse is reviewing a history on a new admission for surgery in the morning. Which long-term medication in the client’s history would be most important to report to the physician?
-
Solution
Answer A is correct. Abrupt withdrawal of steroids can lead to collapse of the cardiovascular system; therefore, the physician should be notified for drug coverage. The medications in answers B, C, and D would not be as important as the maintenance of the steroids. Answer B is an ace-inhibitor used as an antihypertensive. Answer C is a stool softener, and answer D is a calcium and vitamin agent; thus, all are incorrect.
The nurse is caring for a client with chest trauma. Which finding would be most indicative of a tension pneumothorax?
-
Solution
Answer B is correct. Trachea shift differentiates this clinical manifestation as a tension pneumothorax. When a person has a tension pneumothorax, air enters but cannot escape, causing a pressure build-up and a shifting of the great vessels, the heart, and the trachea to the unaffected side. Answer A correlates with a pulmonary contusion, so it is incorrect. Answers C and D are associated with a pneumothorax. This makes them nonspecific for tension pneumothorax and, thus, incorrect.
The physician has prescribed a cleansing enema to a client scheduled for colon surgery. The nurse would place the client:
-
Solution
Answer C is correct. The left Sims position is the best position to use in this case because it follows the natural direction of the colon. Answer A places the client on the abdomen, and answers B and D position the client on the back, so they are all incorrect.
The nurse is preparing a patient for surgery on the lower abdomen. Which position would the nurse most likely place the client in for surgery on this area?
-
Solution
Answer D is correct. The Trendelenburg position is used for surgeries on the lower abdomen and pelvis. This position helps to displace intestines into the upper abdomen and out of the surgical area. Answer A is reserved for vaginal, perineal, and some rectal surgeries. Answer B is used for renal surgery, and answer C is used for back surgery and some rectal surgeries.
The nurse is caring for a client with nausea and vomiting. Laboratory results reveal a potassium level of 2.9mEq. Which ECG finding would the nurse expect to find due to the client’s potassium results?
-
Solution
Answer A is correct. ECG changes associated with hypokalemia are peaked P waves, flat T waves, depressed ST segments, and prominent U waves. Answers B, C, and D are not associated with low potassium levels, so they are incorrect.
Which post-operative assessment finding on a client with a femoral popliteal graft of the right leg would require immediate charge nurse notification?
-
Solution
Answer D is correct. A loss of pulses could indicate an occlusion in the graft, requiring surgical intervention. Answers A and C are expected post-operative occurrences with this surgical procedure, which makes them incorrect. Answer B is not classified as hyperthermia, so it is incorrect.