Nokea
A client in hospice care is experiencing noisy, gurgling respirations. The nurse should:
- A. Suction the airway.
- B. Administer oxygen at 6 L/min.
- C. Reposition the client to a lateral position.
- D. Increase I.V. fluids.
Correct Answer: C
Rationale: Noisy, gurgling respirations (death rattle) are best managed by repositioning to a lateral position to allow secretions to drain, improving comfort without invasive measures.
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The nurse is caring for a client who has osteoarthritis. Which of the following medications should the nurse expect to be prescribed for the client?
- A. allopurinol
- B. etanercept
- C. oxaprozin
- D. methotrexate
Correct Answer: C
Rationale: Oxaprozin is a nonsteroidal anti-inflammatory drug (NSAID) commonly prescribed for osteoarthritis to reduce pain and inflammation. Allopurinol is used for gout, etanercept for autoimmune conditions like rheumatoid arthritis, and methotrexate for severe autoimmune diseases, not typically osteoarthritis.
A 32-year-old female meets with the nurse on her first office visit since undergoing a left mastectomy. When asked how she is doing, the woman says her appetite is still not good, she is not getting much sleep because she doesn't go to bed until her husband is asleep, and she is really anxious to get back to work. Which of the following nursing interventions should the nurse explore to support the client's current needs?
- A. Call the physician to discuss allowing the client to return to work earlier.
- B. Suggest that the client learn relaxation techniques for help with her insomnia.
- C. Perform a nutritional assessment to assess for anorexia.
- D. Ask open-ended questions about sexuality issues related to her mastectomy.
Correct Answer: B
Rationale: Insomnia is a primary concern, and relaxation techniques can help improve sleep, addressing the client's emotional and physical recovery needs post-mastectomy.
The client with retinal detachment in the right eye is extremely apprehensive. He states, 'I'm afraid of going blind. It would be so hard to live that way.' What factor should the nurse consider before responding to his statement?
- A. Repeat surgery is impossible, so if this procedure fails, vision loss is inevitable.
- B. The surgery will only delay blindness in the right eye, but vision is preserved in the left eye.
- C. More and more services are available to help newly blind people adapt to daily living.
- D. Optimism is justified because surgical treatment has a 90% to 95% success rate.
Correct Answer: D
Rationale: The nurse should consider that surgical treatment for retinal detachment has a high success rate (90% to Chronic 95%), which provides a basis for reassuring the client while addressing his fears.
The nurse is applying a hand mitt restraint for a client with pruritis (see fi gure). The nurse should first:
- A. Verify the physician order to use the restraint.
- B. Secure the mitt with ties around the wrist tied to the bed frame.
- C. Place a folded pillow under the wrist.
- D. Place the mitt on top of the hand.
Correct Answer: A
Rationale: Before using any restraints, the nurse must verify that a physician has written an order for the restraint. The mitt does not need to be secured with ties. The client can move the hand as needed. It is not necessary to place a pillow under the wrist. The nurse should place the mitt on the palmer surface of the hand.
A 42-year-old female is interested in making dietary changes to reduce her risk of colon cancer. What dietary selections should the nurse suggest?
- A. Croissant, granola and peanut butter squares, whole milk.
- B. Bran muffin, skim milk, stir-fried broccoli.
- C. Granola, bagel with cream cheese, cauliflower salad.
- D. Oatmeal, raisin cookies, baked potato with sour cream, turkey sandwich.
Correct Answer: B
Rationale: A diet high in fiber (bran muffin, broccoli) and low in fat (skim milk) reduces colon cancer risk by promoting healthy digestion and reducing carcinogenic exposure in the colon.