Nokea
The nurse is preparing to assist a client to ambulate to the bathroom. The client rises from the chair at the bedside and immediately reports feeling dizzy. It would be a priority for the nurse to
- A. Check the client's orthostatic blood pressure
- B. encourage the client to remain on bed rest
- C. apply a gait belt around the client's waist
- D. assist the client back to a sitting position
Correct Answer: D
Rationale: Dizziness upon standing suggests orthostatic hypotension or other instability. Assisting the client back to a sitting position prevents falls and ensures immediate safety.
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The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to
- A. Excessive fetal weight
- B. Low blood sugar levels
- C. Depletion of subcutaneous fat
- D. Progressive placental insufficiency
Correct Answer: D
Rationale: The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia.
The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first?
- A. Weight reduction
- B. Stress management
- C. Physical exercise
- D. Smoking cessation
Correct Answer: D
Rationale: Smoking cessation. Stopping smoking is the priority for clients at risk for cardiac disease, because of its effects of reducing oxygenation and constricting blood vessels.
A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. The nurse should reinforce teaching about which intervention related to the drug's adverse effects?
- A. Have an ophthalmologic examination every 6 months
- B. Take the medication on an empty stomach
- C. Take vitamin D and calcium supplements
- D. Wear a MedicAlert bracelet
Correct Answer: A
Rationale: Hydroxychloroquine can cause retinal toxicity. Regular ophthalmologic exams every 6 months are essential to monitor for early signs of retinal damage.
Spirituality affects a client's life in all of the following areas except:
- A. nutritional intake.
- B. ability to handle stress.
- C. sexual expression.
- D. genetic makeup.
Correct Answer: D
Rationale: Spirituality is a belief in or relationship with some higher power, creative force, divine being, or infinite source of energy and does not have any effect on genetic makeup.
The nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection?
- A. 51-year-old client who received a permanent pacemaker 48 hours ago
- B. 60-year-old client who had a myocardial infarction 24 hours ago
- C. 74-year-old client with stroke and an indwelling urinary catheter for 3 days
- D. 75-year-old client with dementia and dehydration who is on IV fluids
Correct Answer: C
Rationale: An indwelling urinary catheter increases the risk of catheter-associated urinary tract infections, a common nosocomial infection, especially in older adults with prolonged catheter use.