Nokea
A nurse is caring for a client who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied. Which of the following statements by the nurse is appropriate?
- A. Let me provide more stimulation in his environment.
- B. Let's wait until tonight to see if he continues this behavior.
- C. I will call the doctor and get the prescription.
- D. I will cover the catheter so he cannot see it.
Correct Answer: C
Rationale: Obtaining a physician's order is required for restraints, used only as a last resort.
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A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. BUN
- B. Potassium
- C. RBC count
- D. WBC count
Correct Answer: D
Rationale: Elevated WBC count, especially neutrophils, indicates infection response in a pressure ulcer.
A nurse is assisting with teaching a class about minerals. Which of the following minerals is needed for transport of oxygen?
- A. Phosphorus
- B. Iron
- C. Magnesium
- D. Potassium
Correct Answer: B
Rationale: Iron in hemoglobin binds oxygen for transport in the blood.
A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications?
- A. Pulmonary embolism
- B. Diarrhea
- C. Pneumonia
- D. Pressure injury
Correct Answer: C
Rationale: Pneumonia is a primary concern in dysphagia due to aspiration risk, potentially leading to infection.
A nurse is reinforcing teaching with a client who has diabetes mellitus about using a glucometer to monitor her blood glucose. Which of the following actions should the nurse identify as an indication that the client understands the instructions?
- A. Uses the side of a fingertip as the puncture site
- B. Uses the ball of a finger as the puncture site
- C. Avoids using the thumbs as puncture sites
- D. Avoids using the fingers of her dominant hand as puncture sites
Correct Answer: A
Rationale: Using the side of the fingertip is less painful and provides accurate blood samples.
A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Peripheral edema
- C. Oliguria
- D. Bradycardia
Correct Answer: B
Rationale: Peripheral edema occurs in hypervolemia as excess fluid accumulates in tissues.