Nokea
A nurse is caring for an immobile client. What is the priority assessment of this client?
- A. Palpate for edema
- B. Auscultate for bowel sounds
- C. Inspect the skin for injury
- D. Auscultation of lung sounds
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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What is accurate health promotion teaching to prevent ear infection or trauma? (Select all that apply)
- A. Blow nose gently without blocking nostrils
- B. Wear hearing protection when exposed to loud noise
- C. Avoid using cotton-tipped applicators to clean the external ear
- D. All of the above
Correct Answer: D
Rationale: The correct health promotion teachings to prevent ear infection or trauma include blowing the nose gently without blocking nostrils, wearing hearing protection when exposed to loud noise, and avoiding the use of cotton-tipped applicators to clean the external ear. Blocking one nostril when blowing the nose is incorrect, as it can cause problems. Therefore, choice A is inaccurate. Additionally, using cotton-tipped applicators to clean the external ear can lead to trauma or infection, making choice C a correct preventive measure.
The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?
- A. The nurse assesses capillary refill of 2 seconds
- B. The nurse cannot insert one finger between the cast and the skin
- C. The nurse finds 2+ pulses distal from the cast
- D. The nurse does not observe any drainage
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
While completing a health history the client reports experiencing blurring of vision in both eyes without associated pain. What condition does the nurse suspect?
- A. Macular degeneration
- B. Cataract
- C. Retinal detachment
- D. Glaucoma
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What are signs of hearing loss? (Select all that apply)
- A. Answering questions correctly
- B. Presence of cerumen
- C. Tinnitus
- D. Frequent asking of others to repeat statements
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?
- A. Assist the client to orthopneic position
- B. Offer a protein rich diet
- C. Offer the client a bedpan for toileting
- D. Turn the client every 4 hours
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.