Nokea
A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following activities should the nurse perform first?
- A. Administer an antiemetic medication.
- B. Evaluate functioning of the suction device.
- C. Provide oral hygiene care
- D. Replace the NG tube.
Correct Answer: B
Rationale: The correct answer is B: Evaluate functioning of the suction device. First, the nurse needs to ensure proper suction to prevent aspiration and maintain airway patency. This step is crucial for the client's safety and well-being. Administering an antiemetic medication (A) may be necessary but not the first priority. Providing oral hygiene care (C) can wait until after ensuring proper suction. Replacing the NG tube (D) is not necessary unless there are signs of tube malfunction.
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Which of the following statements should the nurse make?
- A. Do you need a prescription for an antianxiety medication?
- B. Do you need information on hospice care?
- C. Would you like to talk to a counselor about advance directives?
- D. Would you like to speak to a spiritual advisor?
Correct Answer: D
Rationale: Spiritual support can help address emotional and existential concerns in terminally ill clients.
Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room.
- B. Use droplet precautions when caring for the child
- C. Assess the child for Koplik spots
- D. Administer aspirin to the child for fever.
Correct Answer: A
Rationale: Negative pressure rooms prevent airborne spread of varicella.
Which of the following actions should the nurse plan to take?
- A. Launch a media campaign to increase awareness about industrial pollution
- B. Have a nurse from outside the community provide health lectures at the county hospital
- C. Encourage rural residents to focus health spending on tertiary health interventions
- D. Provide anticipatory guidance classes to parents through public schools
Correct Answer: D
Rationale: The correct answer is D because providing anticipatory guidance classes to parents through public schools is a proactive approach to promote health and prevent illness in the community. This action empowers parents with knowledge and skills to make informed health decisions for their children. Launching a media campaign (A) may raise awareness but may not directly impact individual behavior change. Having a nurse from outside the community provide health lectures (B) may not be as effective as someone familiar with the community's specific needs. Encouraging rural residents to focus on tertiary health interventions (C) is reactive and may not address prevention.
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has epidural analgesia and weakness in the lower extremities
- B. A client who has a hip fracture and a new onset of tachypnea
- C. A client who has sinus arrhythmia and is receiving cardiac monitoring
- D. A client who has diabetes mellitus and an HbA1c of 6.8%
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client with a hip fracture and new onset of tachypnea first. Tachypnea in this client could indicate a potential complication such as a pulmonary embolism, which is a life-threatening condition requiring immediate intervention. Assessing this client first allows for prompt identification and management of any emergent issues. Clients with epidural analgesia and lower extremity weakness (choice A) may indicate a neurological concern but are not as urgent as tachypnea in a client with a hip fracture. Sinus arrhythmia with cardiac monitoring (choice C) and diabetes mellitus with an HbA1c of 6.8% (choice D) do not present immediate life-threatening situations that require immediate assessment compared to the client with a hip fracture and tachypnea.
Which of the following statements should the nurse make?
- A. We can initiate medical care until you get legal assistance in preparing your advance directives.
- B. Advance directives can be signed without legal representation.
- C. Advance directives can be a verbal agreement between you and your provider until legal review can be obtained.
- D. A social worker will assist you to find affordable legal representation.
Correct Answer: B
Rationale: The correct answer is B: Advance directives can be signed without legal representation. This is correct because advance directives are legal documents that individuals can complete on their own without the need for a lawyer. They allow individuals to specify their healthcare wishes in advance. Choice A is incorrect as medical care can be initiated regardless of advance directives. Choice C is incorrect as advance directives must be in writing to be legally valid. Choice D is incorrect as social workers typically provide support but do not usually offer legal representation.