Nokea
A client with acute leukemia has developed oral ulcerations. The nurse can increase the client's comfort by suggesting that he:
- A. Avoid brushing his teeth until the ulcers heal.
- B. Rinse his mouth frequently with normal saline.
- C. Rinse his mouth frequently with hydrogen peroxide.
- D. Cleanse his teeth and mouth with lemon and glycerin swabs.
Correct Answer: B
Rationale: Normal saline rinses are gentle and help keep the mouth clean without irritating oral ulcerations.
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A client with a temperature of 103°F (39.4°C).
Body compensatory mechanisms would include which of the following?
- A. Decreased respiratory rate and bradycardia.
- B. Normal blood pressure and pulse.
- C. Increased respiratory rate and tachycardia.
- D. Diaphoresis with cool, clammy skin.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) respirations and heart rate will increase with fever (2) blood pressure and pulse usually increase with fever (3) correct-hyperthermia increases the oxygen requirements, which results in faster breathing as well as an increase in the pulse rate (4) diaphoresis may occur, but the skin will be warm
A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to
- A. promote verbal and nonverbal communication with both the client and the interpreter
- B. speak only a few sentences at a time and then pause for a few moments
- C. plan that the encounter will take more time than if the client spoke English
- D. ask the client to speak slowly and to look at the person spoken to
Correct Answer: A
Rationale: The nurse should communicate with the client and the family, not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. Maintain eye contact with both the client and interpreter to elicit feedback and read nonverbal cues.
A client has a cataract removed from the left eye. Which of the following is an important nursing intervention in the immediate postoperative period?
- A. Position the client on the right side with the head slightly elevated.
- B. Place the client on the left side to protect the eye.
- C. Perform sensory neurological checks every two hours.
- D. Maintain complete bedrest for the first 48 hours.
Correct Answer: A
Rationale: Positioning on the right side with head elevation prevents pressure on the surgical eye, reducing complications. Options B, C, and D are incorrect.
A client is admitted with renal calculi and is experiencing severe pain. Meperidine (Demerol) 75 mg IM is given prior to the change of shift.
Which of the following symptoms is MOST important for the nurse to report to the next shift?
- A. Nausea with a small amount of vomitus.
- B. Pain of five on a scale of one to ten.
- C. Change in the location and character of pain.
- D. No known drug allergies.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to renal calculi. (1) often accompanies pain, but is not most important to report to next shift (2) important, but not the highest priority (3) correct-location of the pain depends on location of renal stone; character of pain changes depending on location or movement of stone (4) important, but not the highest priority
A woman has returned from surgery after a right mastectomy with an IV of 0.9% NaCl infusing at 100 cc/hour into her left forearm. Several hours later, the IV infiltrates. The nurse is supervising a student nurse preparing to insert a new peripheral intravenous catheter. The nurse would intervene in which of the following situations?
- A. The student nurse selects a site where the veins are soft and elastic.
- B. The student nurse selects a site on the distal portion of the left arm.
- C. The student nurse selects a site close to the joint to provide for stability.
- D. The student nurse holds the skin taut to stabilize the vein.
Correct Answer: C
Rationale: inappropriate; movement in area could cause displacement