Nokea
A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
- A. Gathering the client's personal belongings
- B. Closing the client's eyes
- C. Washing the client's face
- D. Removing the client's dentures from their mouth
Correct Answer: D
Rationale: Dentures should remain in place to maintain facial structure for family visitation.
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A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Postpone the procedure until the staff contacts the guardian.
- B. Obtain consent from the client.
- C. Request that the provider sign the consent form.
- D. Prepare the client for surgery with implied consent.
Correct Answer: D
Rationale: In emergencies, implied consent allows life-saving procedures when delaying could harm the client.
Findings that require immediate follow-up: deep tendon reflexes 4+, generalized weakness, mild leg cramping, heart rate irregular, bowel sounds hyperactive x 4 quadrants
- A. Deep tendon reflexes 4+
- B. Generalized weakness
- C. Mild leg cramping
- D. Heart rate irregular
- E. Bowel sounds hyperactive x 4 quadrants
Correct Answer: A,B,C,D,E
Rationale: A: Hyperreflexia suggests magnesium deficiency. B,C: Weakness and cramping indicate electrolyte issues. D: Irregular heart rate risks arrhythmia. E: Hyperactive bowels may relate to vomiting.
A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?
- A. Occupational therapist
- B. Registered dietitian
- C. Respiratory therapist
- D. Speech-language pathologist
Correct Answer: D
Rationale: A speech-language pathologist is specifically trained to evaluate and treat swallowing disorders (dysphagia), which makes them the appropriate specialist for this referral.
A nurse is contributing to a community center's in-service program about early detection of breast cancer. Which of the following recommendations should the nurse make for female clients who do not have a family history of breast cancer?
- A. You should start receiving mammograms as early as age 40.
- B. You should receive a breast ultrasound every 3 years after age 50.
- C. You should start performing monthly breast self-examinations at age 35.
- D. You should receive a breast examination from your provider each year after age 30.
Correct Answer: A
Rationale: Mammograms starting at age 40 are recommended for average-risk women.
The first two actions the nurse should take are ___ and ___
- A. Place the client in a private room
- B. Apply supplemental oxygen
Correct Answer: A,B
Rationale: A: Private room isolates TB risk. B: Supplemental oxygen addresses low saturation (88%).