Nokea
A 65-year-old client is admitted after a stroke. The nurse is concerned about skin breakdown and decubitus ulcer development. Which nursing intervention would best improve tissue perfusion to prevent skin problems?
- A. Assessing the skin daily
- B. Massaging any erythematous areas on the skin
- C. Changing incontinence pads as soon as they become soiled
- D. Performing range-of-motion exercises and turning and repositioning the client
Correct Answer: D
Rationale: Performing range-of-motion exercises and turning/repositioning the client promotes blood circulation, which enhances tissue perfusion and prevents pressure ulcers. Assessing the skin detects problems but doesn't improve perfusion, massaging erythematous areas can worsen tissue damage, and changing pads addresses hygiene but not perfusion directly.
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The nurse is caring for a client on airborne precautions. Which of the following would the nurse expect to see in the client's medical record?
- A. measles
- B. influenza
- C. Lyme disease
- D. herpes simplex
Correct Answer: A
Rationale: Measles requires airborne precautions due to its highly contagious nature via respiratory droplets, unlike the other conditions listed.
The nurse is discharging a client with asthma who has a prescription for zafirlukast (Accolate). Which comment by the client would indicate a need for further teaching?
- A. I should take this medication with meals.'
- B. I need to report flulike symptoms to my doctor.'
- C. My doctor might order liver tests while I'm on this drug.'
- D. If I'm already having an asthma attack, this drug will not stop it.'
Correct Answer: A
Rationale: Zafirlukast should be taken on an empty stomach for better absorption. The other statements are correct: flulike symptoms and liver monitoring are relevant, and zafirlukast is not a rescue medication.
The nurse is preparing to walk the postpartum client for the first time since delivery. Before walking the client, the nurse should:
- A. Give the client pain medication
- B. Assist the client in dangling her legs
- C. Have the client breathe deeply
- D. Provide the client additional fluids
Correct Answer: B
Rationale: Dangling the legs before walking helps assess for orthostatic hypotension and ensures the client is stable, reducing the risk of fainting.
A young adult patient constantly seeks attention from the nurses, stomping away from the nurses’ station and pouting when her requests are refused. Which of the following responses by the nurse is MOST appropriate?
- A. Have the patient establish trust with one staff person with whom therapeutic interventions should occur.
- B. Give the patient unsolicited attention when she is not exhibiting the unacceptable behaviors.
- C. Ignore the patient when she exhibits attention-seeking behavior.
- D. Rotate the staff so the patient will learn to relate to more than one nurse.
Correct Answer: B
Rationale: reward nonseeking attention behaviors by giving the patient unsolicited attention
The nursing assistant reports to the nurse that a client who is one-day postoperative after an angioplasty is refusing to eat and states, 'I just don't feel good.' Which of the following actions, if taken by the nurse, is BEST?
- A. The nurse talks with the client about how he is feeling.
- B. The nurse instructs the nursing assistant to sit with the client while he eats.
- C. The nurse contacts the physician to obtain an order for an antacid.
- D. The nurse evaluates the most recent vital signs recorded in the chart.
Correct Answer: A
Rationale: assessment required; monitor for closure of vessel, bleeding, hypotension, dysrhythmias