Nokea
A nurse is collecting data about cranial nerve function from an adult client. Which of the following images depicts the method the nurse should use to check the function of the hypoglossal cranial nerve (XII)?
- A. Image A
- B. Image B
- C. Image C
- D. Image D
Correct Answer: A
Rationale: Image A shows tongue deviation testing, specific to hypoglossal nerve (XII) function.
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A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Use overhead lighting when checking equipment.
- B. Keep the door to the client's room closed.
- C. Provide the client with snug-fitting nightwear.
- D. Administer prescribed diuretics in the evening.
Correct Answer: B
Rationale: Closing the door reduces noise, promoting a sleep-conducive environment.
A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Secure the restraints with a square knot.
- B. Check the client's range of motion every 6 hr.
- C. Make sure two fingers fit under the restraints.
- D. Request a prescription renewal from the provider every 36 hr.
Correct Answer: C
Rationale: Ensuring two fingers fit prevents excessive tightness, promoting circulation and safety.
A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client has poorly fitting dentures.
- B. The client verbalizes regret about never marrying.
- C. The client is sedentary throughout most of the day.
- D. The client has no living family.
Correct Answer: C
Rationale: Sedentary behavior heightens risks like DVT and cardiovascular issues, making it the priority.
A nurse is assisting in the care of a client who is receiving newly prescribed IV antibiotics. Which of the following findings should the nurse report immediately?
- A. Severe wheezing
- B. Rhinitis
- C. Small, raised vesicles over the body
- D. Itching of the skin
Correct Answer: A
Rationale: Severe wheezing suggests anaphylaxis, a life-threatening reaction requiring immediate intervention.
A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?
- A. Pull the client's pinna downward and back.
- B. Cleanse the client's outer ear with isopropyl alcohol to remove wax.
- C. Hold the ear dropper 1 cm (0.5 in) from the client's ear.
- D. Request the client remain supine for 10 min following administration.
Correct Answer: C
Rationale: Holding the dropper 1 cm away ensures accurate delivery without contaminating the ear canal.