Nokea
A client has returned from surgery during which her jaws were wired as treatment for a fractured mandible. The client is in stable condition. The nurse is instructing the unlicensed nursing personnel (UAP) on how to properly position the client. Which instructions about positioning would be appropriate for the nurse to give the UAP?
- A. Keep the client in a side-lying position with the head slightly elevated.
- B. Do not reposition the client without the assistance of a registered nurse.
- C. The client can assume any position that is comfortable.
- D. Keep the client's head elevated on two pillows at all times.
Correct Answer: A
Rationale: A side-lying position with the head slightly elevated helps prevent aspiration and maintains airway patency in a client with wired jaws. The other options are either overly restrictive, unsafe, or not optimal for airway management.
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A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms. Which of the following instructions would be appropriate for the nurse to give the client?
- A. Use your nasal decongestant spray regularly to help clear your nasal passages.
- B. Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.
- C. It is important to increase your activity. A daily brisk walk will help promote drainage.
- D. Keep a diary of when your symptoms occur. This is a very small amount of the drug. You identify what precipitates your attacks.
Correct Answer: D
Rationale: Keeping a symptom diary helps identify triggers for allergic rhinitis, enabling avoidance or management strategies. Overuse of decongestant sprays can cause rebound congestion. Antibiotics are ineffective for allergic rhinitis, which is not bacterial. Increased activity like walking does not directly alleviate allergic rhinitis symptoms.
After an intravenous pyelogram (IVP), the nurse should not include incorporating which of the following measures into the client's plan of care?
- A. Maintaining bed rest.
- B. Encouraging adequate fluid intake.
- C. Assessing for hematuria.
- D. Administering a laxative.
Correct Answer: D
Rationale: Administering a laxative is unnecessary post-IVP, as it does not aid recovery or contrast excretion, unlike fluid intake or hematuria assessment.
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 6 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Which two (2) findings in the nurses' note would require immediate follow-up and reported to the physician?
- A. Rectal temperature
- B. Generalized shivering
- C. Urine output
- D. Assessment of the peripheral pulses
- E. Client reports of thirst
Correct Answer: B,C
Rationale: Generalized shivering may indicate worsening hypothermia or a cooling blanket complication, and low urine output suggests renal hypoperfusion or acute kidney injury, both requiring immediate physician notification. Temperature (A), pulses (D), and thirst (E) are expected or less urgent.
A suspected outbreak of anthrax has been transmitted by skin exposure. A client is admitted to the emergency department with lesions on the hands. The physician prescribes antibiotics and sends the client home. What should the nurse instruct the client to do? Select all that apply.
- A. Take the prescribed antibiotics for 60 days.
- B. Avoid contact with other members of the family during the treatment period.
- C. Wear a mask for 60 days.
- D. Expect the skin lesions to clear up within 1 to 2 weeks.
- E. Wash hands frequently.
Correct Answer: A,D,E
Rationale: Cutaneous anthrax requires antibiotics for 60 days, frequent hand washing to prevent spread, and lesions typically resolve in 1-2 weeks with treatment. Masks and family isolation are unnecessary for cutaneous anthrax.
The nurse is planning a home visit for a client with hepatitis. In order to prevent transmission the nurse should focus teaching on:
- A. Proper food handling.
- B. Insulin syringe disposal.
- C. Alpha-interferon.
- D. Use of condoms.
Correct Answer: D
Rationale: Hepatitis B and C are transmitted via body fluids, so condom use (D) prevents sexual transmission. Food handling (A) is key for hepatitis A, syringe disposal (B) applies to needle-sharing, and alpha-interferon (C) is a treatment, not a preventive measure.