Nokea
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 verbalizes regret about never marrying.
- B. The client has poorly fitting dentures.
- C. The client has no living family.
- D. The client is sedentary throughout most of the day.
Correct Answer: D
Rationale: Sedentary lifestyle is a priority as it poses immediate health risks like thrombosis or muscle atrophy.
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A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
- B. The sterile solution is poured with the bottle held over the field.
- C. Unnecessary sterile items are placed on the field.
- D. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
Correct Answer: B
Rationale: Pouring over the field risks contamination from the bottle.
A nurse is reviewing the medical record of a client. Click to highlight below the findings that require immediate follow-up.
- A. Neurological: Alert and oriented to person, place, and time; deep tendon reflexes 4+
- B. Musculoskeletal: Generalized weakness with equal bilateral muscle strength and mild leg cramping
- C. Respiratory: Lungs clear
- D. Cardiovascular: Heart rate irregular, Heart rate 95/min
- E. Gastrointestinal: Bowel sounds hyperactive x 4 quadrants
Correct Answer: D
Rationale: An irregular heart rate (D) requires immediate follow-up due to potential arrhythmia risks.
A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder. As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, 'I am afraid of needles.' Which of the following actions should the nurse take?
- A. Request a change in the medication route to PO.
- B. Remind the client that they must receive the medication as prescribed.
- C. Tell the client not to worry because the pain will be temporary.
- D. Ask one of the client's loved ones to encourage them to receive the IM
Correct Answer: A
Rationale: Requesting a PO route addresses the client's fear while ensuring treatment continuity.
A nurse is preparing to administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?
- A. Photograph
- B. Medical diagnosis
- C. Room number
- D. Age
Correct Answer: A
Rationale: A photograph is a reliable identifier per safety standards.
The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include? Select all that apply.
- A. Ensure the oxygen delivery system is at least 8 feet from any heat source
- B. Adjust the oxygen flow rate as needed to ease breathing.
- C. Take antibiotic medication with or without food.
- D. Decrease the steroid dose each day.
- E. Take antibiotics for 10 days.
- F. Store the oxygen cylinder wrench with the oxygen tank.
- G. Take steroid medication in the morning.
Correct Answer: A,E,F,G
Rationale: A: Safety precaution. E: Standard antibiotic duration. F: Accessibility for emergencies. G: Morning steroids reduce adrenal suppression.