Nokea
A client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a nursing assistant?
- A. Administer IV fluids as prescribed by the physician.
- B. Provide straws and offer fluids between meals.
- C. Develop plan for added fluid intake over 24 hours.
- D. Teach family members to assist client with fluid intake.
Correct Answer: B
Rationale: The nursing assistant can effectively encourage oral fluid intake by offering fluids between meals, which is within their scope of practice. Administering IV fluids, developing plans, and teaching family members are more advanced tasks that require higher-level nursing skills.
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A client is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?
- A. Pain severity
- B. Wound drainage
- C. Tissue integrity
- D. Airway patency
Correct Answer: D
Rationale: The correct answer is D: Airway patency. Assessing airway patency is the priority in the immediate postoperative period following a laryngectomy to ensure the client's ability to breathe. If the airway is compromised, it can lead to life-threatening complications. Pain severity (A), wound drainage (B), and tissue integrity (C) are important assessments but are secondary to ensuring the client's airway is clear and functioning properly. Prioritizing airway patency allows for prompt intervention if any issues arise, ensuring the client's safety and optimal recovery.
To prevent agitation during the patient's recovery from anesthesia, when should the nurse begin orientation explanations?
- A. When the patient is awake
- B. When the patient first arrives in the PACU
- C. When the patient becomes agitated or frightened
- D. When the patient can be aroused and recognizes where he or she is
Correct Answer: B
Rationale: Early orientation helps prevent confusion and agitation as the patient recovers from anesthesia.
Which concept characterizes culture as continuously evolving?
- A. Learned from birth through language and socialization.
- B. Learned by members of the same cultural group.
- C. Influenced by specific conditions related to environment,technology and availability of resources.
- D. Dynamic and ever-changing.
Correct Answer: D
Rationale: Culture evolves dynamically, adapting to environmental, technological, and resource-related changes over time.
In teaching parents to associate prevention with the lifestyle of their child with sickle cell disease, the nurse should emphasize that a priority for their child is to:
- A. Avoid overheating during physical activities.
- B. Maintain normal activity with some restrictions.
- C. Be cautious of others with viruses or temperatures.
- D. Maintain routine immunizations.
Correct Answer: D
Rationale: Immunizations protect against infections that can trigger crises.
Match the descriptions to the stages of sleep. Some descriptions may have more than one stage and some stages may be used more than once.
- A. Brain waves resemble wakefulness
- B. Deepest sleep, lasting 20 to 40 minutes
- C. Associated with specific EEG waveforms
- D. Most vivid dreaming occurs
Correct Answer: D
Rationale: The correct answer is D (REM). REM sleep is characterized by brain waves resembling wakefulness and vivid dreaming. The deepest sleep (B) corresponds to NREM Stage 3, while specific EEG waveforms (C) are associated with all stages.