Question

A nurse is assisting with the admission of an older adult client. Which of the following subjective findings suggests that the client may have cataracts?

Answer 1

Correct Answers:

Cloudy vision

Rationale :

👁️The lens becomes opaque in cataracts, leading to cloudy vision.

🌫️This change develops gradually, distinguishing cataracts from conditions with sudden vision loss.

🔍Patients often report blurred vision and difficulty seeing in low light due to lens opacification.

💡Symptoms like pain or flashes of light suggest other ocular issues, not cataracts.

📌Core Message

Gradual clouding of the lens causes cloudy vision.

Answer 2

Correct Answers:

Fetal heart rate

Rationale :

🎯Following an amniotomy, the top priority is assessing fetal heart rate to detect any compromise.

💓Changes in fetal heart rate may signal cord prolapse or fetal distress, requiring immediate intervention.

🔍Although monitoring amniotic fluid color and maternal status is important, confirming fetal well-being takes precedence.

⚠️Early identification of abnormal heart rate patterns allows for prompt corrective actions.

📌Core Message

Assessment of fetal heart rate is the priority following amniotomy to ensure fetal well-being.

Answer 3

Correct Answers:

Name and medical record number

Rationale :

🏷️Using name and medical record number provides unique identifiers for each patient.

🔒These primary identifiers reduce the risk of medication errors in the newborn.

👶Supplemental identifiers like footprints or birth date are helpful but secondary to official records.

✅Consistent use of name and medical record number aligns with safety protocols to prevent misidentification.

📌Core Message

Use name and medical record number as primary identifiers to ensure accurate newborn identification.

Answer 4

Correct Answers:

The formula was given immediately following removal from the refrigerator.

Rationale :

🥶Administering cold formula can trigger increased bowel motility, leading to diarrhea.

🍽️Optimal feeding temperature supports digestive enzyme function and nutrient absorption.

🚫Rapid temperature changes may irritate the gastrointestinal mucosa, promoting loose stools.

🔄Ensuring formula is at room temperature helps maintain gut stability and prevent diarrhea.

📌Core Message

Cold formula administration can increase bowel motility and cause diarrhea, so use room temperature formula.

Answer 5

Correct Answers:

Try to complete a task before moving on to the next.

Rationale :

🕑Completing one task at a time enhances focus and prevents multitasking errors.

🎯Sequential task management ensures each activity receives full attention, improving efficiency.

✅Finishing a task before starting the next reduces cognitive overload and missed steps.

🔄This approach promotes a systematic workflow, leading to better time management.

📌Core Message

Focus on one task at a time to enhance efficiency and reduce errors.

Answer 6

Correct Answers:

Hyperkalemia

Rationale :

🔥Full-thickness burns cause cellular destruction, releasing intracellular potassium into circulation.

💥This massive potassium shift leads to hyperkalemia during the emergent phase.

⚡Elevated potassium levels pose a risk for cardiac dysrhythmias and require prompt monitoring.

🛡️Early detection of hyperkalemia allows for timely interventions to prevent complications.

📌Core Message

Cellular destruction in full-thickness burns causes hyperkalemia, risking cardiac dysrhythmias.

Answer 7

Correct Answers:

The client's pedal pulse in the right foot is not palpable.

Rationale :

🚨An absent pedal pulse indicates compromised circulation distal to the bypass graft.

💔Loss of pulse may signal graft occlusion or vascular impairment requiring immediate attention.

🔍Assessment of perfusion through pulse palpation is more reliable than temperature or pain.

✅Early identification of absent pulses allows for prompt interventions to restore blood flow.

📌Core Message

Absence of a pedal pulse indicates impaired circulation and possible graft occlusion.

Answer 8

Correct Answers:

Maintain elbow restraints on the infant.

Rationale :

✋Elbow restraints prevent the infant from touching and traumatizing the repaired palate.

🛡️Protecting the surgical site reduces the risk of wound disruption and infection.

🚫Unrestricted hand movements could lead to bleeding or dehiscence of the repair.

🧒Restraints are used temporarily and should be monitored to ensure comfort and safety.

📌Core Message

Elbow restraints protect the palate repair by preventing self-injury.

Answer 9

Correct Answers:

Report the possible abuse to adult protective services.

Rationale :

🚩Suspected financial exploitation of an older adult is a form of abuse requiring immediate intervention.

🛡️Reporting to adult protective services ensures the client receives legal protection and support.

🔍Timely notification allows for an investigation and resource allocation to safeguard the client.

✅While family involvement may help, mandatory reporting is the first step for safety.

📌Core Message

Suspected financial exploitation must be reported to adult protective services for client safety.

Answer 10

Correct Answers:

Place the client in a room that is ventilated to the outside.

Rationale :

🌬️A negative-pressure room ventilated to the outside prevents airborne spread of TB.

🏥Airborne precautions require controlled airflow to protect other patients and staff.

🦠Gowns are unnecessary for TB precautions, which focus on respiratory protection.

🏭Environmental controls are the primary safeguard against TB transmission; other measures are secondary.

📌Core Message

Use a negative-pressure room ventilated to the outside to prevent airborne TB transmission.

1 :
A nurse is assisting with the admission of an older adult client. Which of the following subjective findings suggests that the client may have cataracts?

2 :
A nurse is assisting with the care of a client who is in active labor. Which of the following data is the priority for the nurse to collect following an amniotomy?

3 :
A nurse is preparing to administer medication to a newborn. Which of the following information should the nurse use to identify the newborn?

4 :
A nurse is collecting data from a client who has a gastrostomy tube and is experiencing diarrhea. Which of the following factors should the nurse identify as a potential cause of the diarrhea?

5 :
A newly licensed nurse is having difficulty finishing client care tasks during their shift. Which of the following techniques should the nurse plan use to assist with time management?

6 :
A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?

7 :
A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?

8 :
A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair. Which of the following actions should the nurse include?

9 :
A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take?

10 :
A nurse is admitting a client who has active tuberculosis. Which of the following nursing interventions is appropriate?

1 : A nurse is assisting with the admission of an older adult client. Which of the following subjective findings suggests that the client may have cataracts?

2 : A nurse is assisting with the care of a client who is in active labor. Which of the following data is the priority for the nurse to collect following an amniotomy?

3 : A nurse is preparing to administer medication to a newborn. Which of the following information should the nurse use to identify the newborn?

4 : A nurse is collecting data from a client who has a gastrostomy tube and is experiencing diarrhea. Which of the following factors should the nurse identify as a potential cause of the diarrhea?

5 : A newly licensed nurse is having difficulty finishing client care tasks during their shift. Which of the following techniques should the nurse plan use to assist with time management?

6 : A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?

7 : A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?

8 : A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair. Which of the following actions should the nurse include?

9 : A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take?

10 : A nurse is admitting a client who has active tuberculosis. Which of the following nursing interventions is appropriate?

1 :
A nurse is assisting with the admission of an older adult client. Which of the following subjective findings suggests that the client may have cataracts?

2 :
A nurse is assisting with the care of a client who is in active labor. Which of the following data is the priority for the nurse to collect following an amniotomy?

3 :
A nurse is preparing to administer medication to a newborn. Which of the following information should the nurse use to identify the newborn?

4 :
A nurse is collecting data from a client who has a gastrostomy tube and is experiencing diarrhea. Which of the following factors should the nurse identify as a potential cause of the diarrhea?

5 :
A newly licensed nurse is having difficulty finishing client care tasks during their shift. Which of the following techniques should the nurse plan use to assist with time management?

6 :
A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?

7 :
A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?

8 :
A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair. Which of the following actions should the nurse include?

9 :
A nurse is caring for an older adult client who states, "I can't pay for my care because my kid took all my money." Which of the following actions should the nurse take?

10 :
A nurse is admitting a client who has active tuberculosis. Which of the following nursing interventions is appropriate?