Nokea
A nurse in an acute care facility is caring for a client who is postop following abdominal surgery. Which of the following behaviors should the nurse identify as increasing the client's risk for constipation?
- A. Regular fluid intake
- B. Urge suppression
- C. Increased physical activity
- D. Adequate dietary fiber
Correct Answer: B
Rationale: Urge suppression can lead to constipation, especially in postoperative patients.
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A nurse is teaching a group of assistive personnel (AP) about the expected integumentary changes in older adults. Which should the nurse include?
- A. Increase in elasticity
- B. Decrease in pigmentation
- C. Decrease in elasticity
- D. Increase in moisture levels
Correct Answer: C
Rationale: Older adults typically experience a decrease in skin elasticity, which can contribute to various skin-related issues.
A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the findings should the nurse expect?
- A. Flaring of the nostrils
- B. Normal respiratory rate
- C. Clear lung sounds
- D. Decreased work of breathing
Correct Answer: A
Rationale: Flaring of the nostrils indicates increased respiratory effort, common in clients with dyspnea due to COPD.
A nurse is performing a focused assessment for a client who has dysrhythmias. What indicates ineffective cardiac contractions?
- A. Increased blood pressure
- B. Pulse deficit
- C. Normal heart rate
- D. Elevated oxygen saturation
Correct Answer: B
Rationale: A pulse deficit indicates ineffective cardiac contractions and the presence of cardiac dysrhythmias.
A nurse is teaching about safety risks for adolescents. What should be included?
- A. Adolescents are more likely to follow rules
- B. Peer influence to participate in high-risk behaviors can lead to injury
- C. Most injuries occur during sports activities
- D. Adolescents are aware of the dangers of substance use
Correct Answer: B
Rationale: Peer influence during adolescence can lead to increased participation in high-risk behaviors, resulting in potential injuries.
A nurse is admitting a client who has meningococcal meningitis. What should the nurse do first?
- A. Initiate droplet precautions
- B. Start intravenous antibiotics
- C. Perform a complete assessment
- D. Notify the healthcare provider
Correct Answer: A
Rationale: Initiating droplet precautions is crucial to prevent the spread of infection, especially in cases of meningococcal meningitis.