Nokea
For each assessment finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock.
- A. Hypercapnia
- B. Muscle rigidity
- C. Tachycardia
- D. Urticaria
- E. Wheezes
Correct Answer:
Rationale: Rationales provided within the question context.
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Which of the following actions should the nurse take?
- A. Limit oral feedings to 30 min in length.
- B. Check the infant's oxygen saturation every 6 hr
- C. Place the infant in the prone position for naps
- D. Weigh the infant every other day.
Correct Answer: A
Rationale: Limiting feeding durations conserves energy for infants with heart failure.
Which of the following information provided by the client indicates improvement? Select all that apply.
- A. The client reports frequent toothaches and lack of dental care
- B. The client makes eye contact and smiles when speaking.
- C. The client's adult child prepares two muss per day for the client.
- D. The client's clothing is clean and appropriate for the weather.
- E. The client has gained 1.11 kg 14 ibL BMI is 18.9
- F. The client receives three baths per week from a home care aide.
Correct Answer: B,C,D,E,F
Rationale: Improvement signs encompass hygiene, nutrition, weight gain, and social interaction.
The nurse should first address the client's.... followed by the client's....
- A. lung, sounds
- B. pain level
- C. bowel sounds
- D. blood glucose level
- E. blood pressure
- F. temperature
Correct Answer: E,F
Rationale: The correct answer is E,F. Firstly, addressing the client's blood pressure (E) is crucial as it assesses cardiovascular health and can indicate potential immediate risks. Secondly, addressing the client's temperature (F) is important as it can indicate infection or other health issues. Choices A, B, C, and D are not the priority as they do not directly relate to immediate cardiovascular or infection risks like blood pressure and temperature do.
For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.
- A. Perform suctioning
- B. Assess for urinary retention.
- C. Assess blood pressure every 15 min
- D. Withhold pain medication for headache until other manifestations resolve.
- E. Place client in supine position
- F. Administer nifedipine.
Correct Answer:
Rationale: Rationales provided within the question context.
A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client,If you don't eat I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?"
- A. Battery
- B. Assault
- C. Negligence
- D. Malpractice
Correct Answer: B
Rationale: The correct answer is B: Assault. Assault refers to the threat of harmful or offensive contact without the actual contact occurring. In this scenario, the AP's statement of putting restraints on the client constitutes a threat of physical harm, which falls under the definition of assault. The nurse should intervene to prevent any potential harm to the client. The other choices are incorrect because: A: Battery involves actual harmful or offensive contact, which has not occurred in this situation. C: Negligence refers to a failure to provide reasonable care, not a threat of harm. D: Malpractice involves professional negligence or misconduct, which is not demonstrated in this scenario.