Nokea
A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?
- A. Speech-language pathologist
- B. Respiratory therapist
- C. Occupational therapist
- D. Registered dietitian
Correct Answer: A
Rationale: A speech-language pathologist specializes in evaluating and treating swallowing difficulties like dysphagia.
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A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Apply clean gloves.
- B. Prick the side of the client's finger.
- C. Squeeze the client's finger until a blood drop forms.
- D. Cleanse the client's finger with an iodine swab.
- E. Elevate the client's hand above the level of the heart
Correct Answer: A,B
Rationale: A: Gloves ensure safety. B: Side of finger is less painful and effective for blood collection.
A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?
- A. You need to talk with your doctor about this.
- B. Not receiving blood will slow down your recovery.
- C. I understand that you decided not to receive blood products.
- D. Why are you refusing to receive blood products?
Correct Answer: C
Rationale: Acknowledging the refusal respects autonomy while opening dialogue.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 5
Rationale: 55 lb = 25 kg; 50 mg/kg/day = 1250 mg/day; 1250 mg / 4 doses = 312.5 mg/dose; 312.5 mg ÷ 125 mg/5 mL = 12.5 mL/day; 12.5 ÷ 4 = 3.125 mL, rounded to 5 mL.
A home health nurse is reinforcing teaching about dietary needs with the child of a client. They state, 'I don't know what to do because they're not eating.' Which of the following responses should the nurse make?
- A. Why do you think they're not eating?
- B. Tell me more about what happens at mealtime.
- C. They may need a feeding tube.
- D. I'm sure it's nothing serious and their appetite will return soon.
Correct Answer: B
Rationale: Exploring mealtime details gathers specific data to address the eating issue effectively.
A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?
- A. Request the client remain supine for 10 min following administration.
- B. Pull the client's pinna downward and back.
- C. Cleanse the client's outer ear with isopropyl alcohol to remove wax.
- D. Hold the ear dropper 1 cm (0.5 in) from the client's ear.
Correct Answer: D
Rationale: Holding the dropper 1 cm above the ear canal ensures safe, accurate administration without contact.