Nokea
A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:
- A. measure intake and output.
- B. check albumin levels.
- C. monitor glucose levels.
- D. increase enteral feeding.
Correct Answer: A
Rationale: The correct action for a client with major head trauma receiving bolus enteral feeding is to measure intake and output (I&O). Enteral feedings are hyperosmotic agents that can cause fluid shifts. Monitoring I&O is crucial to assess fluid balance, ensuring that input matches output. Checking albumin levels (choice B) is important for assessing nutritional status but is not the immediate priority in this situation. Monitoring glucose levels (choice C) is also important but not as critical as measuring I&O in this context. Increasing enteral feeding (choice D) should only be done based on a healthcare provider's order after assessing the patient's condition, not as the most important nursing order at this time.
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What is the most likely reason for a hospitalized adult client who routinely works from midnight until 8 a.m. to have a temperature of 99.1°F at 4 a.m.?
- A. delta sleep
- B. slow brain waves
- C. pneumonia
- D. circadian rhythm
Correct Answer: D
Rationale: The correct answer is 'circadian rhythm.' Circadian rhythms are biological cycles that last about 24 hours. The sleep-wake cycle is closely tied to circadian rhythms, affecting body temperature. Normally, core body temperature drops during sleep, reaching its 24-hour low around 4 a.m. In this case, the client's temperature of 99.1°F at 4 a.m. is likely due to the disruption of their circadian rhythm caused by working from midnight until 8 a.m. Choices A, B, and C are incorrect because delta sleep, slow brain waves, and pneumonia do not directly explain the temperature fluctuation based on circadian rhythm.
Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:
- A. Primary prevention.
- B. Secondary prevention.
- C. Tertiary prevention.
- D. Disability prevention.
Correct Answer: B
Rationale: The correct answer is B: Secondary prevention. Hearing screening for prematurely born infants falls under secondary prevention, which aims to identify and treat a condition in its early stages to prevent further complications. Primary prevention (choice A) focuses on preventing the disease from occurring, while tertiary prevention (choice C) involves managing complications and preventing disability. Choice D, disability prevention, is not a recognized category of prevention. In this context, the screening helps in early identification of hearing loss, allowing for timely intervention to prevent further impairment or complications, aligning with the principles of secondary prevention.
What should be included in the assessment of a client with a cast?
- A. capillary refill, warm toes, no discomfort.
- B. posterior tibial pulses, warm toes.
- C. moist skin essential, pain threshold.
- D. discomfort of the metacarpals.
Correct Answer: A
Rationale: When assessing a client with a cast, it is crucial to check for capillary refill to ensure adequate circulation. Warm toes indicate good circulation, while the absence of discomfort suggests the cast is not causing any pain or undue pressure on the client. Therefore, choices B, C, and D are incorrect as they do not address the essential components of assessing a client with a cast.
Which of the following is not considered one of the five rights of medication administration?
- A. client
- B. drug
- C. dose
- D. routine
Correct Answer: D
Rationale: The five rights of medication administration are dose, client, drug, route, and time. The correct answer is 'routine' as it is not commonly recognized as one of the essential rights in medication administration. Choice A, client, is necessary to ensure the right medication is administered to the right individual. Choice B, drug, is crucial to confirm the correct medication is given. Choice C, dose, is essential to ensure the right amount of medication is administered. Choice D, routine, is not typically included in the five rights of medication administration and is therefore the correct answer.
What condition is mammography used to detect?
- A. pain
- B. tumor
- C. edema
- D. epilepsy
Correct Answer: B
Rationale: Mammography is specifically used to detect tumors or abnormal growths, especially in breast tissue. It is not a tool for identifying pain, edema, or epilepsy. Therefore, the correct answer is 'tumor.' Pain is a symptom, edema is swelling, and epilepsy is a neurological disorder; none of these are conditions typically detected through mammography.