Nokea
A nurse is collecting data from a client who has hypomagnesemia. Which of the following findings should the nurse identify as a positive Chvostek's sign?
- A. Image A
- B. Image B
Correct Answer: A
Rationale: Image A shows facial twitching from tapping the facial nerve, indicating Chvostek’s sign.
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A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?
- A. Conduct staff communications away from the client's room.
- B. Avoid entering the client's room unless requested during the night.
- C. Turn on the client's TV to distract from hallway noise.
- D. Turn off alarms on bedside monitoring equipment.
Correct Answer: A
Rationale: Reducing noise near the client’s room promotes a sleep-friendly environment.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 12.5 mL
Rationale: 55 lb = 25 kg; 25 kg × 50 mg/kg/day = 1250 mg/day; 1250 mg ÷ 4 = 312.5 mg/dose; 312.5 mg ÷ (125 mg/5 mL) = 12.5 mL.
Nurses' Notes Day 1:
Collecting client data on food safety.
Raw meats and raw vegetables are prepared together on one cutting board. Refrigerator is set to 6.7° C (44° F)
Leftovers are discarded after 7 days in refrigerator. Frozen foods are defrosted on the countertop.
Client washes hands for 10 seconds before cooking.
Leftovers are refrigerated after sitting on the countertop for 3 hr.
Reinforced client teaching about food safety. Follow-up visit scheduled in 2 weeks.
Day 14:
At client's home to collect follow-up data on food safety. Uses one cutting board to prepare raw meats and a different cutting board to prepare raw vegetables.
The refrigerator is set to 5.6° C (42° F).
Leftovers are discarded after 2 days in refrigerator. Frozen foods are defrosted in the refrigerator.
Client washes hands for 15 seconds before cooking.
A home health nurse is assisting in the care of a client. Select the 4 findings that indicate an understanding of the reinforced teaching.
- A. Use of cutting board
- B. Amount of time washing hands
- C. Time leftovers sit unrefrigerated on countertop
- D. Refrigerator temperature
- E. Defrosting of frozen foods
- F. Leftover storage time in refrigerator
Correct Answer: A,B,E,F
Rationale:
A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Reposition the client once every 4 hr.
- B. Use a fan to circulate air in the client's room.
- C. Place the head of the client's bed flat.
- D. Provide oral care to the client once every 8 hr.
Correct Answer: B
Rationale: A fan reduces breathlessness sensation, improving comfort in dyspnea.
A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
- A. Inflate the catheter's balloon.
- B. Lower the penis to a 45° angle.
- C. Apply lidocaine gel to the urethra.
- D. Twist the catheter gently.
Correct Answer: D
Rationale: Gentle twisting can navigate urethral obstructions safely without causing trauma.