Nokea
A client who is Muslim is refusing to eat food served to him by a nursing assistant. The nurse should do which of the following? Select all that apply.
- A. arrange a mealtime that will avoid prayer times
- B. remove farm-raised catfish from the food tray
- C. arrange with the family for halal food to be brought from home
- D. deliver food by a nursing assistant of the same sex
Correct Answer: A, C
Rationale: Arranging mealtimes to avoid prayer times and providing halal food respects the client's religious dietary practices. The gender of the assistant and specific foods like catfish are less relevant unless explicitly non-halal.
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Which assessment finding in a client with COPD indicates to the nurse that the respiratory problem is chronic?
- A. Wheezing on exhalation
- B. Productive cough
- C. Clubbing of fingers
- D. Cyanosis
Correct Answer: C
Rationale: Clubbing of fingers is a sign of chronic hypoxia, indicative of long-standing COPD, unlike wheezing or cough, which can occur in acute or chronic stages.
Upon admission to the hospital, a client reports having 'the worst headache I've ever had.' The nurse should give the highest priority to:
- A. Administering pain medication
- B. Starting oxygen
- C. Performing neuro checks
- D. Inserting a Foley catheter
Correct Answer: C
Rationale: A sudden, severe headache may indicate a serious condition like subarachnoid hemorrhage. Neuro checks are the priority to assess for neurological changes.
A 6-month-old client is placed on strict bed rest following a hernia repair. Which toy is best suited to the client?
- A. Colorful crib mobile
- B. Hand-held electronic games
- C. Cars in a plastic container
- D. 30-piece jigsaw puzzle
Correct Answer: A
Rationale: A colorful crib mobile is age-appropriate and safe for a 6-month-old on bed rest, providing visual stimulation.
The nurse is caring for a client with a cerebrovascular accident (CVA) who is complaining of being nauseated and is requesting an emesis basin. Which action would the nurse take first?
- A. Administer an ordered antiemetic
- B. Obtain an ice bag and apply to the client's throat
- C. Turn the client to one side
- D. Notify the physician
Correct Answer: C
Rationale: Turning the client to one side prevents aspiration, a risk in CVA patients with nausea due to impaired swallowing or consciousness. This is the priority before other actions.
The physician has ordered sublingual nitroglycerin for a client. Which of the following are contraindications for administration of sublingual or buccal medications? Select all that apply.
- A. Client is edentulous.
- B. Client has mild dementia.
- C. Mucous membranes are red and irritated.
- D. Client is dehydrated.
- E. Client has productive aphasia.
Correct Answer: C,D
Rationale: Red, irritated mucous membranes (C) and dehydration (D) impair sublingual absorption. Edentulous state (A), mild dementia (B), and aphasia (E) do not contraindicate sublingual administration.