Nokea
A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?
- A. Converse with the client to determine if the mucous membranes are impaired
- B. Report output of less than 30 ml/hr
- C. Provide oral fluids every hour
- D. Check skin turgor every 4 hours
Correct Answer: C
Rationale: Providing oral fluids is a routine task with predictable outcomes, suitable for a UAP, while the other tasks require clinical judgment or assessment skills.
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An 11-year-old boy with a minor head injury treated at the outpatient clinic.
The nurse determines that further teaching is necessary if the mother makes which of the following statements? dimensional visualization of the vertebral canal.'
- A. My son may have dizziness for 24 hours.'
- B. My son can drink carbonated beverages if he vomits.'
- C. My son may complain of nausea.'
- D. My son will probably have a headache.'
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to a minor head injury. (1) expected for at least 24 hours (2) correct-unexpected, should be reported to physician immediately, also unexpected is blurred vision, drainage from ear or nose, weakness, slurred speech, worsening headache (3) expected for at least 24 hours (4) expected for at least 24 hours, should not get more intense
When assessing a client who has just undergone a cardioversion, the practical nurse (LPN) finds the respirations are 12/minute. Which action should the nurse take first?
- A. Try to vigorously stimulate normal breathing
- B. Ask the RN to assess the vital signs
- C. Measure the pulse oximetry
- D. Continue to monitor respirations
Correct Answer: D
Rationale: Continue to monitor respirations. A rate of 12/minute is acceptable post-cardioversion, requiring no immediate intervention.
An older man is being prepared for discharge after treatment for dehydration.
Which of the following statements, if made by the patient to the nurse, indicates that further teaching is needed?
- A. I should weigh myself daily.'
- B. I should drink fluids throughout the day.'
- C. I can use a measuring cup to find out how much I drink during the day.'
- D. I should let my doctor know if I get dizzy when I change positions.'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to dehydration. Be careful, this is a negative question. (1) correct-would only indicate overhydration, not response to dehydration (2) will help prevent recurrence of dehydration, should force fluids to 3,000 cc/day (3) would give good indication of total intake (4) would indicate postural hypotension resulting from volume deficit
At a health-screening clinic, an adult male client's total plasma cholesterol level is 200 mg/dL. The nurse should
- A. advise the client to decrease intake of fatty foods.
- B. schedule the client for a follow-up clinic visit in one month.
- C. inform the client that the cholesterol level is within normal limits.
- D. report the finding to the physician immediately.
Correct Answer: A
Rationale: A cholesterol level of 200 mg/dL is borderline high; reducing fatty foods is appropriate. Options B, C, and D are less immediate or incorrect.
A client with a necrotizing spider bite is to perform his own dressing changes at home.
The nurse is aware that which of the following statements, if made by the client, indicates a correct understanding of aseptic technique?
- A. I need to buy sterile gloves to redress this wound.'
- B. I should wash my hands before redressing my wound.'
- C. I should keep the wound covered at all times.'
- D. I should use an over-the-counter antimicrobial ointment.'
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not most important (2) correct-indicates understanding of asepsis, whose hallmark is handwashing (3) is not possible to carry out (4) should use only the prescribed medications on the wound