Nokea
A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?
- A. Diminished pulses on the affected extremity
- B. Ecchymosis on the inner left thigh
- C. Client report of muscle spasms of the left leg
- D. One fingerbreadth of space between the cast and the skin
Correct Answer: A
Rationale: Diminished pulses suggest vascular compromise, a priority concern.
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A nurse is contributing to the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include?
- A. Monitor the client for 1 hr after meals.
- B. Weigh the client every 2 days.
- C. Check the client's vital signs two times per week.
- D. Allow the client 2 hr to finish meals.
Correct Answer: A
Rationale: Monitoring for 1 hour after meals prevents purging, a key intervention for anorexia.
The client has a chlamydial infection and a new prescription for doxycycline. The client reports nausea and vomiting after starting the medication.
A nurse is caring for a client who has a chlamydial infection and a new prescription for doxycycline. The client reports nausea and vomiting after starting the medication. Which of the following recommendations should the nurse make?
- A. Take the medication with calcium-fortified orange juice.
- B. Take the medication with crackers.
- C. Take the medication and then lay down for 30 min.
- D. Take the medication with an antacid.
Correct Answer: B
Rationale: Taking doxycycline with crackers reduces GI upset without affecting absorption.
The client has mild hypertension.
A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should exercise for 15 minutes two times per week.
- B. I should decrease my salt intake to 2 grams per day.
- C. I will set my blood pressure goal at 130 over 84.
- D. I can have two glasses of wine with dinner.
Correct Answer: B
Rationale: Reducing salt to 2 grams daily helps manage hypertension, showing understanding.
While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications.
A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?
- A. Autonomy
- B. Justice
- C. Veracity
- D. Beneficence
Correct Answer: C
Rationale: Veracity reflects truthfulness, as the nurse honestly discusses medication adverse effects.
A nurse is reinforcing teaching about circumcision care with the parent of an infant who just underwent a Plastibell circumcision. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will wipe away yellow crusts that form around the incision.
- B. I will make sure that my baby's diaper is applied snugly.
- C. I will apply pressure with gauze if I see bleeding.
- D. I will apply antibiotic ointment to my baby's penis.
Correct Answer: C
Rationale: Applying pressure with gauze controls bleeding, a key aspect of Plastibell circumcision care.