Nokea
A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?
- A. Painful areas should be rubbed gently until the pain subsides.
- B. Wearing gloves when handling cold items guards against painful spasms.
- C. Return appointments will be needed for IV pain medication.
- D. Enrolling in a pain clinic can provide pain relief alternatives.
Correct Answer: B
Rationale: Wearing gloves prevents cold-induced spasms, reducing pain in Raynaud's disease.
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The nurse is caring for a patient with a burn that is severely swollen, and the wound bed appears brown and yellow. The patient reports no pain. How should the nurse classify the depth of this burn?
- A. Superficial partial-thickness.
- B. Full-thickness.
- C. Deep partial-thickness.
- D. Deep full-thickness.
Correct Answer: B
Rationale: A painless, brown/yellow, swollen burn indicates full-thickness damage, involving the epidermis and dermis.
The nurse is preparing a client for discharge who was recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in this client's discharge teaching plan?
- A. Take prescribed cortisone accurately.
- B. Use a walker when weakness occurs.
- C. Avoid extreme environmental temperatures.
- D. Increase daily intake of sodium in diet.
Correct Answer: A
Rationale: Accurate cortisone administration is vital to manage Addison's disease and prevent adrenal crisis.
A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement?
- A. Document the findings.
- B. Elevate the extremity.
- C. Apply gentle pressure.
- D. Assess the client's temperature.
Correct Answer: A
Rationale: A bruit indicates a patent AV graft, a normal finding that should be documented.
How many drops per minute should the nurse set for the infusion? The patient has been prescribed 1 liter of 0.9% sodium chloride, USP to be administered intravenously (IV) over a period of 4 hours. The IV administration set delivers 10 drops/mL.
- A. 40 gtt/min
- B. 42 gtt/min
- C. 44 gtt/min
- D. 46 gtt/min
Correct Answer: B
Rationale: Calculating 1000 mL ÷ 240 min × 10 gtt/mL yields 41.7 gtt/min, rounded to 42 gtt/min.
Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?
- A. Lean beef, salads, and baked potatoes.
- B. Potatoes, low-fat breads, and applesauce.
- C. Oatmeal, raisins, and fruit with skin.
- D. Chicken, rice, and wheat products.
Correct Answer: C
Rationale: High-fiber foods like oatmeal, raisins, and fruit with skin reduce colorectal cancer risk by promoting gut health.