Nokea
A 6-month-old client is placed on strict bed rest following a hernia repair. Which toy is best suited to the client?
- A. Colorful crib mobile
- B. Hand-held electronic games
- C. Cars in a plastic container
- D. 30-piece jigsaw puzzle
Correct Answer: A
Rationale: A colorful crib mobile is age-appropriate and safe for a 6-month-old on bed rest, providing visual stimulation.
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The nurse is caring for a client who just had a supratentorial craniotomy to remove a tumor. The nurse will implement which of the following in the client's plan of care? Select all that apply.
- A. check the dressing every 8 hours for excessive drainage
- B. assess the pupils for signs of increased intracranial pressure
- C. position the client flat with the head rotated away from the surgical site
- D. monitor the client's respiratory status, including rate and pattern of breathing
- E. notify the health care provider if the dressing is saturated or the client has more than 50 mL of drainage in 8 hours
Correct Answer: B, D, E
Rationale: Monitoring pupils, respiratory status, and excessive drainage are critical to detect complications like increased intracranial pressure. Positioning flat is incorrect; the head should be elevated.
A community center is having a health fair. Which of the following main food courses should the nurse recommend as most healthful for a 20-year-old adult whose total cholesterol level is 300 mg/dL?
- A. fettuccine alfredo
- B. fried chicken
- C. grilled cheese sandwich with bacon
- D. natural peanut butter and banana sandwich on whole wheat bread
Correct Answer: D
Rationale: The peanut butter and banana sandwich on whole wheat bread is lower in saturated fats and healthier for managing high cholesterol.
Which nurse should be assigned to care for the postpartal client with preeclampsia?
- A. The RN with 2 weeks of experience in postpartum
- B. The RN with 3 years of experience in labor and delivery
- C. The RN with 10 years of experience in surgery
- D. The RN with 1 year of experience in the neonatal intensive care unit
Correct Answer: B
Rationale: The RN with labor and delivery experience is best equipped to manage preeclampsia complications in a postpartal client.
A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be
- A. confused with cold, clammy skin and a pulse of 110.
- B. lethargic with hot, dry skin and rapid, deep respirations.
- C. alert and cooperative with a BP of 130/80 and respirations of 12.
- D. short of breath, with distended neck veins and a bounding pulse of 96.
Correct Answer: A
Rationale: symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL
The nurse is caring for a client who is receiving mechanical ventilation. The ventilator alarms are sounding, and the nurse notes high-pressure alarms. Which of the following actions should the nurse take FIRST?
- A. Suction the client’s airway.
- B. Notify the respiratory therapist.
- C. Check the ventilator tubing for kinks.
- D. Administer a bronchodilator.
Correct Answer: C
Rationale: checking for kinks in the tubing is the first step, as it is a common cause of high-pressure alarms