Nokea
A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?
- A. Use a pad and paper.
- B. Use a picture or word board.
- C. Have the family interpret needs.
- D. Devise a system of hand signals.
Correct Answer: B
Rationale: For a tracheostomy client, a picture or word board (B) is easiest, allowing quick, clear communication without speech. Paper (A) requires literacy and dexterity. Family interpretation (C) is unreliable. Hand signals (D) need setup. B is correct. Rationale: Visual aids bypass vocal limitations, enhancing autonomy, a practical solution per speech therapy standards.
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An infant with Tetralogy of Fallot is discharged with a prescription for Lanoxin elixir. The nurse should instruct the mother to:
- A. Administer the medication using a nipple
- B. Administer the medication using the calibrated dropper in the bottle
- C. Administer the medication using a plastic baby spoon
- D. Administer the medication in a baby bottle with 1oz of water
Correct Answer: B
Rationale: Using the calibrated dropper ensures accurate dosing of Lanoxin (digoxin) elixir for an infant with Tetralogy of Fallot, critical due to its narrow therapeutic range and cardiac effects. Nipples, spoons, or dilution in bottles risk under- or overdosing. Nurses teach this method to parents, stressing precision to manage heart defects safely, preventing toxicity or inefficacy.
A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature?
- A. Oral
- B. Axillary
- C. Arterial line
- D. Rectal
Correct Answer: B
Rationale: Axillary avoids the oral route post-surgery and is appropriate for a flushed, warm client.
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should tell the parents:
- A. That the infant will need daily calcium supplements
- B. To lift the infant by the buttocks when diapering
- C. That the condition is a temporary one
- D. That only the bones are affected by the disease
Correct Answer: B
Rationale: Lifting by the buttocks prevents fractures in osteogenesis imperfecta, a brittle bone disorder calcium doesn't strengthen defective collagen, it's lifelong, and other systems (e.g., hearing) may be affected. Nurses teach gentle handling, ensuring safety in this genetic condition.
Which of the following statement is TRUE about reimbursement?
- A. Free care
- B. Payment for services
- C. Only from patients
- D. All of the above
Correct Answer: B
Rationale: Reimbursement is payment for services (B), per system e.g., insurer pays for Mr. Gary. Not free (A), not patient-only (C), not all (D) service-based. B truly defines reimbursement's role, compensating care, making it correct.
When giving a client a diagnosis of acute pain, the nurse 'using NANDA diagnostic categories' will use this diagnosis only when the pain last no longer than which of the following lengths of time?
- A. 3 days
- B. 2 weeks
- C. 1 month
- D. 6 months
Correct Answer: D
Rationale: NANDA defines acute pain as lasting up to 6 months, beyond which it's chronic. Nurses use this timeframe for diagnosis accuracy.