Nokea
Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.
- B. I can visit my nephew who has chickenpox S days after the sores have crusted.
- C. I can clean my cat's litter box during my pregnancy.
- D. I should wish my hands for 10 seconds with hat water after working in the garden.
Correct Answer: B
Rationale: Chickenpox sores crust over before becoming non-contagious.
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Which of the following medications should the nurse administer?
- A. Bisacodyl 10 mg rectal suppository
- B. Magnesium hydroxide 30 mL PO
- C. Famotidine 20 mg PO
- D. Loperamide 4 mg PO
Correct Answer: A
Rationale: The correct answer is A: Bisacodyl 10 mg rectal suppository. Bisacodyl is indicated for immediate relief of constipation as a rectal suppository. It acts directly on the colon to stimulate peristalsis and promote bowel movement. The rectal route ensures faster onset of action compared to oral medications, making it suitable for a patient needing immediate relief. Magnesium hydroxide (B) is a laxative taken orally, which may not provide quick relief. Famotidine (C) is for acid reflux, not constipation. Loperamide (D) is an antidiarrheal agent, not appropriate for constipation.
Which of the following is an appropriate action by the nurse?
- A. Suggest rinsing his mouth with an alcohol-based mouth wash
- B. Provide humidification of the room air.
- C. Offer the client saltine crackers between meals
- D. Instruct the client on the use of esophageal speech
Correct Answer: B
Rationale: The correct answer is B: Provide humidification of the room air. Humidification helps to moisturize the air, making it easier for the client to breathe, especially if they have dry mouth or throat. This can improve comfort and prevent irritation. Choice A is incorrect because alcohol-based mouthwash can further dry out the mouth. Choice C is incorrect as saltine crackers can exacerbate dry mouth. Choice D is incorrect as esophageal speech is not related to addressing dry mouth.
Which of the following tasks should the charge nurse assign to a licensed practical nurse?
- A. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus.
- B. Complete the Glasgow Coma Scale for a client who has an evolving stroke.
- C. Perform a sterile dressing change for a client who has an abdominal wound.
- D. Perform an admission assessment for a client who is scheduled for surgery.
Correct Answer: C
Rationale: LPNs are trained for sterile dressing changes.
The nurse should first address the client's.... followed by the client's....
- A. lung, sounds
- B. pain level
- C. bowel sounds
- D. blood glucose level
- E. blood pressure
- F. temperature
Correct Answer: E,F
Rationale: The correct answer is E,F. Firstly, addressing the client's blood pressure (E) is crucial as it assesses cardiovascular health and can indicate potential immediate risks. Secondly, addressing the client's temperature (F) is important as it can indicate infection or other health issues. Choices A, B, C, and D are not the priority as they do not directly relate to immediate cardiovascular or infection risks like blood pressure and temperature do.
A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning.(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Apply suction while rotating the catheter.
- B. Rinse the catheter to remove secretions:
- C. Dan sterile gloves.
- D. Insert the catheter during the client's inspiration.
- E. Turn on the suction and set the pressure
Correct Answer: C,D,E,A,B
Rationale: To perform nasotracheal suctioning correctly, the nurse should follow these steps:
1. Dan sterile gloves (C): Ensures aseptic technique to prevent infection.
2. Insert the catheter during the client's inspiration (D): Reduces the risk of hypoxia and trauma.
3. Turn on the suction and set the pressure (E): Prepares the equipment for suctioning.
4. Apply suction while rotating the catheter (A): Maximizes removal of secretions.
5. Rinse the catheter to remove secretions (B): Ensures cleanliness of the catheter for next use.
Other choices are incorrect:
- F and G are not applicable in this sequence as they do not contribute to the safe and effective performance of nasotracheal suctioning.