Nokea
A nurse is in the emergency department monitoring the hydration status of a client receiving oral rehydration. What should the nurse intervene for?
- A. Heart rate 120/min
- B. Urine output 30 mL/hour
- C. Blood pressure 110/70 mmHg
- D. Skin turgor is normal
Correct Answer: A
Rationale: A heart rate of 120/min may indicate dehydration or inadequate hydration, prompting the need for IV fluid replacement.
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A nurse is providing discharge teaching to a client who has a prescription for home oxygen. Which information should the nurse teach?
- A. Use a humidifier with the oxygen
- B. Wear cotton socks when the oxygen is in use
- C. Avoid all types of smoking materials
- D. Use a nasal cannula during meals
Correct Answer: B
Rationale: Wearing cotton socks helps prevent static electricity, which poses a fire risk when using oxygen.
A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?
- A. Use sterile gloves only if needed
- B. Restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray
- C. Keep the dressing tray on the client's bed
- D. Avoid talking during the procedure
Correct Answer: B
Rationale: If liquid comes in contact with the sterile field at any point, it is considered contaminated and unsterile, necessitating the restart of the procedure.
A nurse is assisting a client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery. Which of the following statements should the nurse make?
- A. You should not worry about it
- B. The surgeon will answer your questions before surgery
- C. It's too late to cancel the surgery
- D. You need to trust the medical team
Correct Answer: B
Rationale: The nurse should encourage the client to express concerns and ensure that the surgeon addresses any questions prior to the procedure.
A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?
- A. Applesauce
- B. Mashed potatoes
- C. Orange slices
- D. Soft bread
Correct Answer: C
Rationale: Orange slices have membranes that are hard to swallow, which can be problematic for clients on a mechanical soft diet.
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.