Nokea
A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?
- A. Oranges
- B. Potatoes
- C. Grapes
- D. Corn
Correct Answer: C
Rationale: Grapes are correct. Whole grapes are a known choking hazard for toddlers due to their size and shape, which can easily obstruct the airway. They should be cut into smaller pieces to reduce the risk.
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A nurse is caring for a client who has a new diagnosis of Raynaud's disease. Which of the following findings should the nurse expect?
- A. Cold fingers
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Cold fingers, often with color changes, are a hallmark symptom of Raynaud's disease due to vasospasm.
A nurse is caring for a client who has a new prescription for fluoxetine. Which of the following adverse effects should the nurse monitor for?
- A. Weight loss
- B. Bradycardia
- C. Hypotension
- D. Insomnia
Correct Answer: D
Rationale: Fluoxetine, an SSRI, can cause insomnia due to its stimulatory effect on the central nervous system.
A nurse is reinforcing teaching with a client who is scheduled for a Holter monitor. Which of the following instructions should the nurse include?
- A. Avoid showering while wearing the monitor.
- B. Exercise more than usual during the test.
- C. Remove the monitor before sleeping.
- D. Keep a diary of activities.
Correct Answer: D
Rationale: Keeping a diary of activities helps correlate symptoms with heart rhythm changes recorded by the Holter monitor.
A nurse is reinforcing teaching with a client who has a new prescription for an epinephrine auto-injector. Which of the following instructions should the nurse include?
- A. Store the injector in the refrigerator.
- B. Inject into the thigh.
- C. Shake the injector before use.
- D. Apply pressure for 30 seconds after injection.
Correct Answer: B
Rationale: Injecting into the thigh ensures rapid absorption of epinephrine to treat anaphylaxis effectively.
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?
- A. Check the tube cuff pressure every 8 hours.
- B. Suction the tube every 4 hours.
- C. Reposition the tube every 12 hours.
- D. Clean the tube with alcohol-based solution.
Correct Answer: A
Rationale: Checking the tube cuff pressure every 8 hours ensures it remains within a safe range to prevent tracheal damage or air leaks.