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. Washing the client's face
- B. Gathering the client's personal belongings
- C. Closing the client's eyes
- D. Removing the client's dentures from their mouth
Correct Answer: D
Rationale: Removing dentures distorts facial appearance, requiring intervention.
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A nurse is caring for a client who follows a lacto-vegetarian diet. Which of the following food choices should the nurse recommend?
- A. Tuna fish
- B. Clam chowder
- C. Cheese
- D. Chicken
Correct Answer: C
Rationale: Cheese fits a lacto-vegetarian diet, which includes dairy but excludes meat and fish.
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?
- A. 12.5 mL (calculated: 55 lb = 25 kg, 50 mg/kg = 1250 mg/day, 1250 mg / 4 doses = 312.5 mg/dose, 312.5 mg / 125 mg/5 mL = 12.5 mL)
Correct Answer: A
Rationale: Calculation confirms 12.5 mL per dose is correct.
A nurse is checking for proper placement of a feeding tube. Which of the following methods is the most reliable for verification of tube placement?
- A. Verify the bilirubin level of the tube contents.
- B. Auscultate for air insufflation.
- C. Request a chest x-ray.
- D. Check the pH level of gastric contents.
Correct Answer: C
Rationale: A chest x-ray is the gold standard for confirming feeding tube placement.
Nurses' Notes
Vital Signs
Diagnostic Results
6 months ago:
Client present today for annual examination. Reports lack of sleep and increased stress due to moving and starting a new job.
Today, 1400:
Client presents to office today with reports of fatigue. Client states they have difficulty sleeping without drinking four or five beers a night. Client reports, "I sometimes get headaches along with nausea and vomiting. I have been busy with my new job, so I have been eating a lot of fast food, and I've gained 15 pounds."
Today, 1445.
Provider notified of laboratory results.
A nurse is assisting in the care of a client in a provider's office. A nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe?
- A. Administer a diuretic.
- B. Limit alcohol intake to 2 drinks per day.
- C. Keep daily fat intake to less than 35%
- D. Place on 2300 mg sodium diet.
- E. Administer an antibiotic
- F. Limit foods high in potassium.
Correct Answer: A, B, C, D
Rationale: A: Addresses fluid retention from fast food. B, C, D: Manage weight gain and hypertension risks.
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should move my stronger leg forward before moving my weaker leg.
- B. I will hold the cane on my stronger side.
- C. I will move the cane forward 18 inches.
- D. I should wear shoes with smooth soles to help slide my weak leg forward.
Correct Answer: B
Rationale: Holding the cane on the stronger side provides optimal support.