Nokea
A client with a history of heart failure is admitted with dyspnea. Which position should the nurse place the client in?
- A. Fowler's position
- B. Supine with legs elevated
- C. Prone position
- D. Trendelenburg position
Correct Answer: A
Rationale: Fowler's position (semi-upright) reduces preload and eases breathing in heart failure clients with dyspnea.
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A client admitted in an acute psychotic state says that she hears terrible voices in the head and thinks her neighbor is out to get her. Which of the following is the nurse's best response?
- A. What has your neighbor been doing that bothers you?'
- B. How long have you been hearing these terrible voices?'
- C. I won't let your neighbor visit, so you'll be safe.'
- D. What exactly are these terrible voices saying to you?'
Correct Answer: D
Rationale: Asking about the content of the voices helps assess the nature of the hallucinations and potential risks, guiding therapeutic intervention.
An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. The nurse should advise the mother to do which of the following?
- A. Notify the physician immediately to adjust the treatment plan.
- B. Confine the infant to one room in the apartment.
- C. Keep the infant in the splint at night, removing it during the day.
- D. Remove any unsafe items from the area in which the infant is mobile.
Correct Answer: D
Rationale: Removing unsafe items ensures the infant's safety while mobile in a splint, preventing further injury. The other options are unnecessary or impractical.
You are asked by your supervisor to take photographs of the residents and their family members who are attending a holiday dinner and celebration at your long term care facility. What should you do?
- A. Take the photographs because these photographs are part of the holiday tradition at this facility
- B. Take the photographs because all of the residents are properly attired and in a dignified condition
- C. Refuse to take the photographs unless you have the consent of all to do so
- D. Refuse to take the photographs because this is not part of the nurse's role
Correct Answer: C
Rationale: Taking photographs without the explicit consent of all residents and family members violates their privacy rights under HIPAA . Consent must be obtained to ensure compliance with privacy regulations.
A client with a diagnosis of diabetes insipidus asks the nurse about the purpose of the vasopressin she has been prescribed. The nurse responds, knowing that this medication promotes which action?
- A. Vasodilation
- B. Decrease in peristalsis
- C. Decrease in urinary output
- D. Inhibit smooth muscle contraction
Correct Answer: C
Rationale: Vasopressin is a vasopressor and an antidiuretic. It directly stimulates contraction of smooth muscle, causes vasoconstriction, stimulates peristalsis, and increases reabsorption of water by the renal tubules, resulting in decreased urinary output.
The doctor orders a midstream urine specimen for your client who is an alert, oriented and ambulatory female client. What element should you include in your instructions to this client on the proper manner to collect this specimen?
- A. The need to cleanse the perineal area with circular wipes.
- B. The need to cleanse the perineal area from the 'dirtiest' to the 'cleanest'.
- C. The need to use a new antiseptic wipe for each wipe from the inner to the outer labia.
- D. The need to use a new antiseptic wipe for each wipe from the outer to the inner labia.
Correct Answer: C
Rationale: For a midstream urine specimen, the perineal area should be cleansed from front to back (inner to outer labia) using a new antiseptic wipe for each stroke to prevent contamination.