Nokea
A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply.
- A. Ask a family member about the client's preferences for room arrangement
- B. Offer the client an elbow to hold, and walk a half-step ahead for guidance
- C. Say 'goodbye' when leaving the room to help orient the client
- D. Speak slowly and slightly louder so the client can understand
- E. Use a clock-face pattern to explain food arrangement on the client's meal tray
Correct Answer: B,C,E
Rationale: Guiding with an elbow , saying goodbye , and clock-face food arrangement promote safety and orientation. Family input is secondary, and louder/slower speech is unnecessary unless hearing-impaired.
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A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the most important reason for this diet is to
- A. Promote healing and strengthen the immune system
- B. Provide a well balanced nutritional intake
- C. Stimulate increased peristalsis absorption
- D. Spare protein catabolism to meet metabolic needs
Correct Answer: D
Rationale: Spare protein catabolism to meet metabolic needs. A high-carbohydrate diet prevents protein breakdown for energy, allowing proteins to restore tissue.
Propranolol is prescribed for an adult suspected to have Graves' disease. The nurse explains to the client that propranolol is prescribed for which purpose?
- A. To decrease the activity of the thyroid gland
- B. To provide the hormone the client is missing
- C. To regulate the client's metabolism
- D. To slow the heart rate
Correct Answer: D
Rationale: Propranolol, a beta-blocker, slows heart rate, controlling tachycardia in Graves' disease (hyperthyroidism). It does not affect thyroid activity, provide hormones, or regulate metabolism.
The nurse has taught the parents of a 6-year-old client with cystic fibrosis who has a prescription for pancreatic enzymes. Which of the following statements by a parent would require follow-up?
- A. It is acceptable for my child to chew the medication before swallowing it
- B. I should give the medication with or just before my child has a meal or snack
- C. I need to monitor the total amount of medication that I give to my child every day.
- D. It is acceptable to open the capsule and sprinkle the medication on a tablespoon of applesauce.
Correct Answer: A
Rationale: Chewing pancreatic enzymes destroys the enteric coating, reducing efficacy. Timing with meals , monitoring doses , and sprinkling on applesauce are correct practices.
The nurse reinforces teaching about the use of the peak flow meter to evaluate airflow to a client newly diagnosed with asthma. Which statement by the client indicates an understanding of the nurse's teaching?
- A. I will exhale a complete breath as quickly as possible through the mouthpiece of the device to obtain a peak flow reading
- B. I will move the indicator to the desired reading on the numbered scale before using the device
- C. I will record the lowest of 3 consecutive peak flow readings in my asthma journal every day.
- D. I will remember to use the device after taking my fluticasone via metered-dose inhaler.
Correct Answer: A
Rationale: Exhaling quickly is the correct technique for peak flow. Setting the indicator , recording the lowest reading , and using post-inhaler are incorrect.
The nurse is reinforcing teaching about newly prescribed clonidine for a client with hypertension. Which of the following information would be most important for the nurse to reinforce?
- A. Avoid consuming high-sodium foods
- B. Do not stop taking the medication abruptly
- C. Limit alcohol intake while taking the medication
- D. Use an oral moisturizer to relieve dry mouth
Correct Answer: B
Rationale: Abruptly stopping clonidine can cause rebound hypertension, a critical risk. Sodium , alcohol , and dry mouth are less urgent.