Nokea
A nurse is caring for a client who ingested a poison and is now having seizures. Which of the following is the priority action the nurse should take?
- A. Maintain the patency of the client's airway.
- B. Identify the poison the client ingested.
- C. Measure the client's blood pressure.
- D. Position the client on her side.
Correct Answer: A
Rationale: Airway patency is the priority during seizures to prevent aspiration and ensure adequate oxygenation.
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A nurse is monitoring a client for complications of immobility. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Contractures of extremities
- B. Hypertension
- C. Diarrhea
- D. Crackles in the lungs
- E. Pressure ulcers
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. Contractures of extremities occur due to prolonged immobility. Crackles in the lungs can result from immobility-related respiratory complications. Pressure ulcers are common in immobile clients due to prolonged pressure on bony prominences. Hypertension and diarrhea are not typically associated with complications of immobility.
A nurse is collecting data about a client's pulmonary system. While auscultating the client's lungs, the nurse hears continuous gurgling, low-pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?
- A. Rhonchi
- B. Crackles
- C. Wheezing
- D. Friction rub
Correct Answer: A
Rationale: The correct answer is A: Rhonchi. Rhonchi are continuous low-pitched gurgling sounds heard over the trachea and bronchi. These sounds are typically caused by the movement of air through narrowed airways due to secretions or inflammation. Crackles (B) are discontinuous, popping sounds typically heard during inspiration and caused by fluid in the alveoli. Wheezing (C) is a high-pitched musical sound heard on expiration and caused by narrowed airways. Friction rub (D) is a grating, rubbing sound heard during inspiration and expiration and is typically associated with inflammation of the pleura.
A nurse is reviewing the laboratory results of a client and notes a calcium level of 7.2 mg/dL. Which of the following findings should the nurse expect?
- A. Hypoactive deep-tendon reflexes
- B. Numbness of extremities
- C. Dry, sticky mucous membranes
- D. Decreased bowel sounds
Correct Answer: B
Rationale: The correct answer is B: Numbness of extremities. A calcium level of 7.2 mg/dL indicates hypocalcemia, which can lead to neuromuscular excitability and tingling sensations. Numbness of extremities is a common symptom of hypocalcemia due to its effect on nerve function. Hypoactive deep-tendon reflexes (choice A) are associated with hypercalcemia, not hypocalcemia. Dry, sticky mucous membranes (choice C) are more indicative of dehydration. Decreased bowel sounds (choice D) may be seen in conditions affecting the gastrointestinal tract, but are not directly related to calcium levels.
A nurse is caring for an older adult client who has dementia and wanders at night. Which of the following interventions should the nurse take?
- A. Assign the client to a quiet room away from the nurses' station.
- B. Elevate the four side rails on the client's bed at night time.
- C. Encourage the client to rest during the day.
- D. Take the client to the bathroom on a regular schedule.
Correct Answer: D
Rationale: The correct answer is D: Take the client to the bathroom on a regular schedule. This is the most appropriate intervention as older adults with dementia may have difficulty expressing their needs and may forget to use the bathroom. Establishing a routine for bathroom breaks can prevent accidents and promote comfort. Choice A is incorrect as isolating the client may increase agitation. Choice B is incorrect as using all four side rails can be a safety hazard and restrict mobility. Choice C is incorrect as it does not address the specific issue of wandering at night.
A nurse whose left hand is dominant is preparing to perform a straight catheterization for a client who is paraplegic. Which of the following actions should the nurse take?
- A. Use the left hand to cleanse the urinary meatus.
- B. Use the right hand to insert the catheter.
- C. Stand on the client's right side.
- D. Raise the bed to a comfortable working height.
Correct Answer: D
Rationale: The correct answer is D: Raise the bed to a comfortable working height. This is important to prevent strain on the nurse's back and ensure proper ergonomics during the procedure. Standing on the client's right side (Choice C) does not directly impact the procedure. Using the left hand to cleanse the urinary meatus (Choice A) could be challenging for a left-handed nurse and may not be as efficient. Using the right hand to insert the catheter (Choice B) could also be difficult for a left-handed nurse and may affect dexterity. Therefore, raising the bed to a comfortable working height is the most appropriate action to ensure the nurse's comfort and safety while performing the catheterization.