Nokea
A nurse is caring for a patient who is scheduled for cataract surgery. The client states, "I see just fine and have decided to cancel my surgery." Which of the following responses should the nurse make?
- A. That's not a good idea; the surgery is necessary
- B. Share with me more about the thoughts that are concerning you
- C. You should trust your doctor's advice
- D. You can always reschedule the surgery later
Correct Answer: B
Rationale: Encouraging the client to share their thoughts helps the nurse understand the client's concerns and facilitates a supportive discussion.
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A nurse is admitting a client who has meningococcal meningitis. What should the nurse do first?
- A. Initiate droplet precautions
- B. Start intravenous antibiotics
- C. Perform a complete assessment
- D. Notify the healthcare provider
Correct Answer: A
Rationale: Initiating droplet precautions is crucial to prevent the spread of infection, especially in cases of meningococcal meningitis.
A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the findings should the nurse expect?
- A. Flaring of the nostrils
- B. Normal respiratory rate
- C. Clear lung sounds
- D. Decreased work of breathing
Correct Answer: A
Rationale: Flaring of the nostrils indicates increased respiratory effort, common in clients with dyspnea due to COPD.
A nurse is teaching about measures to promote sleep for a client with insomnia. What statement indicates understanding?
- A. I should reduce my fluid intake to 2 hours before bedtime
- B. I will watch TV in bed before sleeping
- C. I can take long naps during the day
- D. I should exercise right before going to bed
Correct Answer: A
Rationale: Reducing fluid intake to 2-4 hours before sleeping helps prevent interruptions during the night, promoting better sleep.
A charge nurse is making assignments for the upcoming shift. What assignment should the charge nurse give to an LPN?
- A. A client who requires complex medication management
- B. A client who has dehydration and inflammatory bowel disease (IBD)
- C. A client needing assessment of a new diagnosis
- D. A client requiring a nursing care plan update
Correct Answer: B
Rationale: A client with dehydration and IBD does not require complex medication administration, making this an appropriate assignment for an LPN.
A nurse is monitoring a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?
- A. Increased appetite
- B. Nausea
- C. Weight gain
- D. Regular bowel movements
Correct Answer: B
Rationale: Nausea is a sign of intolerance to enteral feedings, which may also include vomiting and dumping syndrome.