Nokea
A nurse is caring for a 65-year-old male client in the emergency department. The client is presenting with symptoms of a potential cardiac event and has been admitted for further evaluation. Complete the following sentence by selecting the most appropriate actions based on the client’s current status. The nurse should first ___ then ___.
- A. Notify the primary health care provider immediately.
- B. Start an IV line for potential medication administration.
- C. move patient to ICU
Correct Answer: A,B
Rationale: A: Notifying the provider addresses potential cardiac event urgency. B: IV line ensures rapid medication access.
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A nurse is collecting data from a client who has diabetes mellitus. The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?
- A. Do you have any problems taking care of your feet?
- B. Do you go barefoot at home?
- C. Have you noticed any problems with foot swelling?
- D. Have you had a problem with ingrown toenails?
Correct Answer: A
Rationale: This directly assesses ability to perform foot care, critical for diabetes management.
A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder. As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, 'I am afraid of needles.' Which of the following actions should the nurse take?
- A. Remind the client that they must receive the medication as prescribed.
- B. Tell the client not to worry because the pain will be temporary.
- C. Request a change in the medication route to PO.
- D. Ask one of the client's loved ones to encourage them to receive the IM medication.
Correct Answer: C
Rationale: Requesting a PO route addresses the client’s fear while ensuring treatment.
A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?
- A. I might have headaches due to a decline in my estrogen levels.
- B. I should stop receiving Papanicolaou tests once I reach menopause.
- C. I can expect to have regular periods until I am in menopause.
- D. The best time to perform a breast self-examination is on the first day of my period.
Correct Answer: A
Rationale: Declining estrogen can cause headaches, reflecting perimenopause symptoms.
A nurse is reinforcing teaching with an older adult client about the aging process. The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)
- A. Increased peripheral circulation.
- B. Increased constipation.
- C. Decreased muscle mass.
- D. Decreased cough reflex.
Correct Answer: B,C,D
Rationale: B: Reduced motility causes constipation. C: Sarcopenia reduces muscle mass. D: Weaker cough reflex increases aspiration risk.
A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?
- A. Encourage your partner to eat three large meals each day.
- B. Opioids will be restricted if your partner develops respiratory distress.
- C. We will use an electric blanket to keep your partner warm.
- D. Assume your partner can hear you, even if they do not respond.
Correct Answer: D
Rationale: Hearing may persist, so speaking provides comfort and connection.