The nurse is caring for a female client who has been seen at the ED multiple times recently for sexually transmitted infections and various physical concerns. When the client's boyfriend goes for coffee, what is the priority nursing action?

Look for tattooing or 'branding' marks.

Complete a psychosocial assessment.

Ask, "Does anyone you know make you feel unsafe?"

Follow agency policy for contacting local authorities to report the concern

Answer and Explanation

The Correct Answer is C

A. While looking for tattooing or 'branding' marks can provide evidence of abuse, it is not the first action. This is part of a physical assessment, which should follow establishing safety and rapport with the client.

B. Completing a full psychosocial assessment is important, but first the nurse must ensure the client is in a safe environment to disclose sensitive information. A comprehensive assessment can be conducted after addressing immediate safety concerns.

C. The priority is to assess for safety and potential abuse. Asking a direct, nonjudgmental question like, "Does anyone you know make you feel unsafe?" allows the client an opportunity to disclose abuse in a safe and private setting. Safety is always the first priority when domestic or intimate partner violence is suspected.

D. Following agency policy for reporting is important, but it is not the first action. Nurses must first assess the situation and confirm immediate safety needs before initiating reports. Immediate reporting without client disclosure or context may not address urgent safety concerns.

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Correct Answer is D

Explanation

A. This is incorrect.

B. This is incorrect.

C. This is incorrect.

D. Step 1: Convert the patient’s weight from pounds to kilograms
Weight (kg) = 198 ÷ 2.2
Weight (kg) ≈ 90 kg

Step 2: Calculate the Heparin drip rate in units/hr
Drip rate (units/hr) = 16 units/kg/hr × 90 kg
Drip rate = 1,440 units/hr

Step 3: Determine the concentration of the Heparin bag
Concentration = 12,500 units ÷ 250 mL
Concentration = 50 units/mL

Step 4: Calculate the flow rate in mL/hr
Flow rate (mL/hr) = Drip rate ÷ Concentration
Flow rate = 1,440 ÷ 50
Flow rate = 28.8 mL/hr

Step 5: Match the calculated flow rate to the options
28.8 mL/hr

Final Answer: D. 28.8 mL/hr

A. "I prop myself up at night to sleep." B. "I decided to put on some makeup today." C. I have a productive cough in the morning." D. "I have gained weight since I was here last."

Correct Answer is A

Explanation

A. The statement "I prop myself up at night to sleep"indicates orthopnea, which is difficulty breathing when lying flat. Orthopnea occurs because in clients with COPD, the lungs have reduced elastic recoil and airflow obstruction, leading to air trapping and hyperinflation. When lying flat, the diaphragm is compressed, and the lungs cannot fully expand, worsening shortness of breath. Needing to use pillows or sit upright to sleep is a key sign of worsening respiratory function or increased dyspnea. This symptom signals that the client’s COPD may be progressing or that there is an acute exacerbation, requiring prompt assessment of oxygenation, lung sounds, and respiratory effort.

B. Saying "I decided to put on some makeup today"reflects engagement in activities of daily livingand suggests that the client has functional capacity and energy. This statement does not indicate increased shortness of breath.

C. A productive morning coughis a chronic symptom of COPD caused by excess mucus productionand impaired mucociliary clearance. While it is part of the disease process, it does not necessarily indicate an acute increase in dyspneaunless it is accompanied by other symptoms such as increased sputum, wheezing, or shortness of breath.

D. Weight gaincould be related to fluid retention, dietary changes, or other factors, but on its own it does not directly indicate worsening dyspnea. If associated with edema or orthopnea, it may suggest heart failure, but without these signs, it is not the primary indicator of increased respiratory distress.

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The nurse is caring for a female client who has been seen at the ED multiple times recently for sexually transmitted infections and various physical concerns. When the client's boyfriend goes for coffee, what is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client with COPD who smokes 1 PPD presents for a routine appointment. Which client statement causes the nurse to suspect an increase in dyspnea?

Correct Answer is A

Explanation

A client is on mechanical ventilator settings that include the use of PEEP (positive end-expiratory pressure). Which finding indicates the client is developing a complication related to this therapy and requires immediate treatment?

The nurse is assessing a client who sustained a blunt chest injury. Which would indicate to the nurse that the client is exhibiting a flail chest?

The nurse is assessing a client who is in shock. Which of the following findings would indicate to the nurse that the client is entering an irreversible stage?

A patient receiving treatment for a pneumothorax calls on the call light to tell you something is wrong with their chest tube. When you arrive to the room you note that the drainage system has fallen on its side and there is a large crack in the system. What is your next PRIORITY?

Which one of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client?

The nurse is teaching the spouse of a client on mechanical ventilation about measures to prevent ventilator associated pneumonia. Which of the following statements by the family would indicate to the nurse that the family would indicate to the nurse that the family needs additional instruction?

Which of the following interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)?

The nurse is teaching a group of staff nurses about complications associated with a tracheostomy. Which of the following conditions would the nurse include? Select all that apply