Nokea
A client with chronic bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep. The client can feel thick mucus in the chest and throat. Which teaching can the nurse reinforce to help the client mobilize secretions and improve sleep? Select all that apply.
- A. Increase fluids to at least 8 glasses (2-3 L) of water a day
- B. Sleep with a cool mist humidifier
- C. Take prescribed guaifenesin cough medicine before bedtime
- D. Use abdominal breathing and the huff cough technique at bedtime
- E. Use pursed lip breathing during the night
Correct Answer: A,B,C,D
Rationale: Fluids , humidifiers , guaifenesin , and huff coughing thin and mobilize secretions. Pursed lip breathing aids exhalation, not secretion clearance.
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The nurse is talking with the parents of a 2 year old client about nutritional choices to promote growth and development. The family observes a strict vegan diet. Which of the following information should the nurse include? Select all that apply.
- A. Diets consisting of legumes as the only protein source are sufficient for growth.
- B. Green, leafy vegetables such as cabbage and broccoli are good sources of calcium.
- C. Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake
- D. Sunlight, mushrooms, and fortified,subscribe plant based milks are good sources of vitamin D.
- E. Try to consume foods high in iron with foods high in vitamin C to increase iron absorption.
Correct Answer: B,D,E
Rationale: Leafy greens provide calcium, sunlight/mushrooms/fortified milks supply vitamin D, and vitamin C with iron enhances absorption. Legumes alone lack essential amino acids, and vegetables/fruits don't provide B12.
Which of the following nursing assessment findings require immediate discontinuance of an antipsychotic medication?
- A. Involuntary rhythmic stereotypic movements and tongue protrusion
- B. Cheek puffing, involuntary movements of extremities and trunk
- C. Agitation, constant state of motion
- D. Hyperpyrexia, severe muscle rigidity, malignant hypertension
Correct Answer: D
Rationale: Hyperpyrexia, severe muscle rigidity, and malignant hypertension are signs of neuroleptic malignant syndrome (NMS), requiring immediate discontinuation of the antipsychotic.
The nurse is about to medicate a client who is to have surgery today. The client says, 'I do not understand what the doctor is going to do,' and asks the nurse to explain specific details of the surgery. The client has already signed an operative permit. What is the best action for the nurse to take at this time?
- A. Attempt to answer the client's questions
- B. Notify the physician of the client's concerns prior to medicating the client
- C. Reassure the client that the physician is well respected and very competent
- D. Suggest that the client ask the physician her questions when in the operating room
Correct Answer: B
Rationale: The client's lack of understanding indicates a need for clarification before proceeding. Notifying the physician ensures informed consent is valid, delaying medication that may impair judgment.
The nurse is to administer a tube feeding to a client. Before administering the feeding, what is essential for the nurse to do?
- A. Ask the client if she feels full
- B. Aspirate the nasogastric tube and check for acid
- C. Change the tubing
- D. Feel over the end of the tube and do not administer if air is felt
Correct Answer: B
Rationale: Aspirating and checking for acidic pH confirms nasogastric tube placement in the stomach, preventing aspiration. Other actions are irrelevant or unsafe.
The precepting nurse supervising a graduate practical nurse would need to intervene when the graduate nurse violates the Health Insurance Portability and Accountability Act with which action? Select all that apply.
- A. Accesses the medical record of a client not currently assigned, but previously cared for, to assess client improvement.
- B. Advises the client transport technician, 'This client has fragile bones due to cancer, so move the client very carefully.'
- C. Asks a client, 'When were you diagnosed with diabetes?' in a semi-private room with the privacy curtain in place between beds.
- D. Interprets the results of a client's diagnostic testing to the unit clerk
- E. Writes a client's last name and room number on a whiteboard hanging in the nurse's station on which scheduled procedures are logged
Correct Answer: A,D,E
Rationale: Accessing unassigned records , sharing results with a clerk , and writing names on a public whiteboard violate HIPAA. Sharing relevant care info and private questioning are permissible.