Nokea
A client with a history of chronic obstructive pulmonary disease (COPD) is being discharged with home oxygen therapy. Which statement by the client indicates a need for further teaching?
- A. I will keep my oxygen tank upright at all times.
- B. I will not use petroleum jelly to keep my nose from drying out.
- C. I will not smoke or allow others to smoke around me.
- D. I will call my doctor if I have difficulty breathing.
Correct Answer: B
Rationale: The correct answer is B. Petroleum jelly is flammable and should not be used with oxygen therapy as it can increase the risk of fire. Using petroleum jelly near oxygen can lead to a fire hazard. Choices A, C, and D are correct statements that indicate proper understanding of oxygen therapy safety measures. Choice A emphasizes the importance of keeping the oxygen tank upright to prevent leaks, choice C highlights the necessity of avoiding smoking to prevent exacerbation of COPD, and choice D encourages seeking medical help promptly in case of breathing difficulties.
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The nurse is caring for a patient diagnosed with diabetes. Which task will the nurse assign to the nursing assistive personnel?
- A. Providing nail care
- B. Teaching foot care
- C. Making the patient's bed
- D. Determining aspiration risk
Correct Answer: C
Rationale: The correct answer is making the patient's bed. Delegating bed-making tasks to nursing assistive personnel is appropriate as it falls within their scope of practice and helps free up the nurse's time to focus on tasks that require their specialized skills and knowledge. Providing nail care and teaching foot care involve direct patient care and education, which should be performed by licensed nursing staff. Determining aspiration risk requires critical thinking and clinical judgment, making it a responsibility of the nurse.
A client in a provider's office tells the nurse that, 'I fast for several days each week to help control my weight.' The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that result from fasting puts her at risk for medication toxicity?
- A. Increasing the metabolism of the medications over time
- B. Increasing the protein-binding response
- C. Increasing medications' transit time through the intestines
- D. Decreasing the excretion of medications
Correct Answer: B
Rationale: Fasting can lead to an increased protein-binding response of medications. This can result in a higher concentration of bound medications in the bloodstream, potentially causing toxicity as the medications may not be readily available for metabolism or excretion. Choice A is incorrect because fasting typically doesn't increase medication metabolism. Choice C is incorrect as fasting usually decreases transit time through the intestines. Choice D is incorrect since fasting generally does not decrease medication excretion.
A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client fell out of bed. Which of the following statements should the nurse document?
- A. "Client found lying on the floor."
- B. "Client fell out of bed and was found on the floor."
- C. "Client experienced a fall from the bed."
- D. "Client was discovered on the floor following a fall from the bed."
Correct Answer: B
Rationale: The correct answer is B. The documentation should be clear and precise, providing details about the context of the fall. Choice A is vague and does not specify the cause of the client being on the floor. Choice C is less specific and does not directly state that the client fell from the bed. Choice D is wordy and less direct compared to option B, which clearly states that the client fell out of bed and was found on the floor.
The healthcare professional is preparing to administer a tuberculin skin test. Which site is most appropriate for this injection?
- A. Deltoid muscle
- B. Vastus lateralis muscle
- C. Abdomen
- D. Inner forearm
Correct Answer: D
Rationale: The inner forearm is the most appropriate site for administering a tuberculin skin test. This test requires an intradermal injection, which is administered just below the surface of the skin. The inner forearm provides a flat, easily accessible surface for this type of injection. Choices A, B, and C are incorrect because the tuberculin skin test should not be administered into a muscle (deltoid muscle or vastus lateralis muscle) or into the abdomen. The test requires precise placement within the dermal layer of the skin on the inner forearm to accurately assess for a reaction.
A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first?
- A. Give the client information about immunization against meningitis.
- B. Tell the client to have a TB skin test every 2 years.
- C. Determine the client's health risks.
- D. Teach the client about exercise recommendations.
Correct Answer: C
Rationale: Assessing the client's health risks is the priority as it provides essential information to guide subsequent care. By understanding the client's health risks, the nurse can tailor health education and interventions, such as immunizations and lifestyle modifications, to address specific needs. Providing information about immunization against meningitis (Choice A) is important but should come after assessing health risks. Instructing the client to have a TB skin test every 2 years (Choice B) is relevant but not the initial step in care. Teaching about exercise recommendations (Choice D) is also essential but should follow the assessment of health risks.