Nokea
A client is transferred to the neurology unit after developing right-sided paralysis and aphasia. Which of the following should be included in the patient's plan of care?
- A. Encourage client to shake head in response to questions.
- B. Speak in a loud voice during interactions.
- C. Speak using phrases and short sentences.
- D. Encourage the use of radio to stimulate the client.
Correct Answer: C
Rationale: will decrease tension and anxiety; client may understand some of the incoming communication if it is kept simple; speech may be relearned with appropriate support and interventions
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A client admitted four days ago for treatment of alcohol dependence is now displaying the following symptoms: slurred speech, ataxia, uncoordinated movements, and headache. Which of the following nursing actions should be taken FIRST?
- A. Observe the client for eight hours to collect additional data.
- B. Perform a complete physical assessment.
- C. Collect a urine specimen for a drug screen.
- D. Encourage the client to talk about whatever is bothering him.
Correct Answer: B
Rationale: best way to identify possible physical complications of alcohol dependence is through a complete physical assessment
The physician orders cholestyramine (Questran) 4 g PO qid for a 40-year-old client. The medication is provided in single-dose 4 g packets. The client asks the office nurse how to take the medication. The nurse should instruct the client to
- A. sprinkle the powder on a beverage, stir, and drink immediately.
- B. sprinkle the powder on food and eat slowly.
- C. add water to make a paste and eat, followed by 8 oz of water.
- D. sprinkle the powder on a beverage, let it stand a few minutes, and then stir and drink.
Correct Answer: D
Rationale: ensures uniform suspension
A 20-year-old woman calls the outpatient clinic to schedule her first Papanicolaou's smear. The nurse should instruct the client to
- A. avoid intercourse for 48 hours before the examination.
- B. avoid douching for 24 hours prior to her appointment.
- C. withhold all foods and fluids 12 hours before the appointment.
- D. save her first voided urine specimen the morning of her appointment.
Correct Answer: B
Rationale: douching would affect appearance of cells in vaginal smear, would make test inaccurate
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min via nasal cannula. The client reports increased shortness of breath. Which of the following actions should the nurse take FIRST?
- A. Increase the oxygen flow to 4 L/min.
- B. Check the client's oxygen saturation.
- C. Place the client in a supine position.
- D. Administer a bronchodilator as ordered.
Correct Answer: B
Rationale: checking oxygen saturation provides objective data to assess the client's respiratory status
The nurse has just received report from the previous shift. Which of the following clients should the nurse see FIRST?
- A. A client with chronic renal failure complaining of swollen fingers and ankle edema.
- B. A client one-day postoperative after abdominal surgery who has dried blood on the abdominal dressing.
- C. A client with type I diabetes mellitus who states, 'I have this quivering feeling in my abdomen.'
- D. A client on high doses of antibiotics for a resistant infection who complains of diarrhea.
Correct Answer: C
Rationale: indicates hypoglycemia; symptoms include tachycardia, cold and clammy skin, weakness and pallor; check blood sugar, offer milk