Nokea
A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?
- A. turning out the room light and closing the door
- B. tiring the child during the evening with play exercises
- C. identifying the child's home bedtime rituals and following them
- D. encouraging visitation by friends during the evening
Correct Answer: C
Rationale: Preschool-age children require bedtime rituals that should be followed in the hospital if possible. Choice 1 increases a child's fear. Choices 2 and 4 do not promote sleep.
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A 45-year-old client with type I diabetes is in need of support services upon discharge from a skilled rehabilitation unit. Which of the following services is an example of a skilled support service?
- A. shopping for groceries
- B. house cleaning
- C. transportation to physician's visits
- D. medication instruction
Correct Answer: D
Rationale: The only skilled service listed is medication instruction. Grocery shopping, house-cleaning services, and transportation services are all examples of unskilled services offered by volunteer and fee-for-service agencies.
The goals of palliative care include all of the following except:
- A. giving clients with life-threatening illnesses the best quality of life possible.
- B. taking care of the whole person-body, mind, spirit, heart, and soul.
- C. no interventions are needed because the client is near death.
- D. support of needs of the family and client.
Correct Answer: C
Rationale: The goals of palliative care include choices A, B, and D. Choice C is not part of palliative care. All aspects of medical, emotional, social, and spiritual needs of the dying client should be focused on until the end of life.
The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?
- A. Pureed canned squash
- B. Pureed apples
- C. Yogurt
- D. Infant rice cereal
Correct Answer: D
Rationale: Infant rice cereal is recommended as a first solid food due to its digestibility and added iron, suitable for infants starting solids.
A client has a nasogastric (NG) tube in place following abdominal surgery. The purpose of this tube immediately following surgery is to:
- A. simplify medication administration
- B. measure accurate input and output
- C. prevent accumulation of fluids and gas
- D. facilitate collection of specimens
Correct Answer: C
Rationale: Postoperative NG tubes decompress the stomach, preventing fluid and gas buildup that could disrupt surgical sites or cause vomiting.
A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?
- A. calcium
- B. magnesium
- C. potassium
- D. sodium chloride
Correct Answer: D
Rationale: Duodenal intestinal fluid is rich in K+, Na+, and bicarbonate. Suctioning to remove excess fluids decreases the client's K+ and Na+ levels.