Nokea
A nurse is assessing a client who has circulatory overload. Which of the following findings should the nurse expect?
- A. Diaphoresis
- B. Weight loss
- C. Hypotension
- D. Tachycardia
Correct Answer: D
Rationale: The correct answer is D: Tachycardia. In circulatory overload, the body is trying to compensate for the increased volume of fluid in the circulatory system by increasing the heart rate to maintain adequate circulation. Diaphoresis (A) is excessive sweating, not typically associated with circulatory overload. Weight loss (B) is not expected as circulatory overload is characterized by excess fluid retention. Hypotension (C) is unlikely as the body's response to fluid overload is to increase blood pressure. Tachycardia (D) is the correct choice as the heart rate increases to help pump the excess fluid throughout the body.
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A nurse is observing a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
- A. Holds their hands below elbows while rinsing off soap
- B. Uses hot water to wash their hands
- C. Turns off the faucet with their hands
- D. Washes their hands for 10 seconds
Correct Answer: A
Rationale: The correct answer is A because holding hands below elbows while rinsing off soap prevents contamination of clean hands by dirty water. This action ensures proper hand hygiene by maintaining a unidirectional flow of water from clean to dirty areas. Choice B using hot water is incorrect as it may cause skin irritation. Choice C turning off the faucet with hands can reintroduce contamination. Choice D washing hands for only 10 seconds is insufficient for effective hand hygiene.
A nurse is preparing to perform hand hygiene with an alcohol-based hand sanitizer. Which of the following actions should the nurse plan to take?
- A. Use hot water to rinse hand sanitizer off
- B. Dry hands with a reusable towel
- C. Rub hands together 20 seconds
- D. Rub hand sanitizer around rings on fingers
Correct Answer: D
Rationale: The correct answer is D: Rub hand sanitizer around rings on fingers. This is important because rings can harbor bacteria and viruses, and by rubbing hand sanitizer around them, the nurse ensures that all surfaces of the hands, including under the rings, are effectively sanitized. This action helps prevent the transmission of pathogens.
A: Using hot water to rinse hand sanitizer off is unnecessary and can actually be harmful as it can cause skin irritation.
B: Drying hands with a reusable towel is not recommended as it can harbor germs and compromise hand hygiene.
C: Rubbing hands together for 20 seconds is a good practice, but the specific action related to rings is more crucial.
E, F, G: No information provided.
A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?
- A. Cataracts
- B. Diabetic retinopathy
- C. Macular degeneration
- D. Glaucoma
Correct Answer: A
Rationale: The correct answer is A: Cataracts. Cataracts cause a cloudy, opaque area over the lens of the eye, leading to blurred vision. This occurs due to the clouding of the lens from protein buildup. Diabetic retinopathy, choice B, involves damage to blood vessels in the retina due to diabetes. Macular degeneration, choice C, affects the central part of the retina leading to distortion or loss of central vision. Glaucoma, choice D, is characterized by increased pressure within the eye damaging the optic nerve. In this scenario, the cloudy, opaque area over the lens specifically points towards cataracts, making it the correct choice.
A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Teach the use of an incentive spirometer to a postoperative client
- B. Irrigate and perform a dressing change for a client who has a pressure injury wound
- C. Administer oral PRN pain medication to a client who has arthritis
- D. Obtain a daily weight on a client who has heart failure
Correct Answer: D
Rationale: The correct answer is D: Obtain a daily weight on a client who has heart failure. The rationale is as follows: Delegating the task of obtaining a daily weight to an assistive personnel (AP) is appropriate because it is a routine, non-invasive task that does not require specialized knowledge or skills. Daily weight monitoring is crucial for clients with heart failure to assess for fluid retention or loss, which is essential for managing the condition effectively. APs are trained to perform basic tasks like measuring weight and can report any significant changes to the nurse for further evaluation.
Summary of why the other choices are incorrect:
A: Teaching the use of an incentive spirometer requires specialized knowledge and skill that only a nurse should perform.
B: Irrigating and performing a dressing change for a pressure injury wound requires sterile technique and assessment skills that are beyond the scope of an AP.
C: Administering PRN pain medication involves assessing the client's condition, pain level, and potential side effects,
A nurse is taking care of a patient that has a new prescription for labetalol (beta blocker). What adverse effect should the nurse include in the medication education?
- A. Hypokalemia
- B. Bleeding
- C. Bradycardia
- D. Seizures
Correct Answer: C
Rationale: The correct answer is C: Bradycardia. Labetalol is a beta blocker that slows down the heart rate by blocking beta-adrenergic receptors. This can lead to bradycardia, which is a slow heart rate. The nurse should educate the patient about this potential adverse effect to prevent any complications.
Hypokalemia (choice A) is not a common adverse effect of labetalol. Bleeding (choice B) is not directly associated with beta blockers like labetalol. Seizures (choice D) are not a typical adverse effect of labetalol. Therefore, the correct answer is C as it directly correlates with the mechanism of action of labetalol.