Nokea
A 75-year-old male client has a history of macular degeneration. While he is in the hospital, the priority nursing goal will be:
- A. To provide education regarding community services for clients with adult macular degeneration (AMD).
- B. To provide health care related to monitoring his eye condition.
- C. To promote a safe, effective care environment.
- D. To improve vision.
Correct Answer: C
Rationale: Promoting a safe, effective care environment is the priority to prevent falls and injuries due to impaired central vision in a hospital setting.
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A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the physician with the recommendation for:
- A. Initiating I.V. sedation.
- B. Starting a high-protein diet.
- C. Providing pain medication.
- D. Increasing the ventilator rate.
Correct Answer: A
Rationale: Increasing peak pressures, respiratory rate, and poor PO2 suggest agitation or asynchrony; I.V. sedation improves ventilator synchrony. Diet and pain medication are irrelevant. Increasing ventilator rate may worsen lung injury.
The nurse sees a client walking in the hallway who begins to have a seizure. The nurse should do which of the following in priority order?
- A. Maintain a patent airway.
- B. Record the seizure activity observed.
- C. Ease the client to the floor.
- D. Obtain vital signs.
Correct Answer: C,A,B,D
Rationale: The priority order is: 1) Ease the client to the floor to prevent injury (C); 2) Maintain a patent airway to ensure oxygenation (A); 3) Record seizure activity for accurate reporting (B); 4) Obtain vital signs post-seizure to assess stability (D).
Following a total hip replacement, the nurse should do which of the following? Select all that apply.
- A. With the aid of a coworker, turn the client from the supine to the prone position every 2 hours.
- B. Encourage the client to use the overhead trapeze to assist with position changes.
- C. For meals, elevate the head of the bed to 90 degrees.
- D. Use a fracture bedpan when needed by the client.
- E. When the client is in bed, prevent thromboembolism by applying thigh-high antiembolism stockings.
Correct Answer: B,D,E
Rationale: Using a trapeze, fracture bedpan, and antiembolism stockings supports recovery and prevents complications. Prone positioning and 90-degree elevation risk dislocation.
A client with a surgical wound reports itching around the incision site on postoperative day 5. The nurse should:
- A. Apply an antihistamine cream.
- B. Assess the wound for signs of infection.
- C. Instruct the client to avoid scratching.
- D. Clean the wound with alcohol.
Correct Answer: C
Rationale: Itching is common during healing, but scratching can disrupt the incision. Instructing the client to avoid scratching prevents wound dehiscence while further assessment can rule out infection.
A client with microcytic anemia is having trouble selecting food from the hospital menu. Which food is best for the nurse to suggest for satisfying the client's nutritional needs?
- A. Egg yolks.
- B. Brown rice.
- C. Vegetables.
- D. Tea.
Correct Answer: A
Rationale: Microcytic anemia is often due to iron deficiency. Egg yolks are a good source of iron, particularly heme iron, which is highly bioavailable. Brown rice and vegetables contain non-heme iron but in lower amounts, and tea inhibits iron absorption due to tannins. Egg yolks are the best choice.