Nokea
A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?
- A. Request the client remain supine for 10 min following administration.
- B. Pull the client's pinna downward and back.
- C. Cleanse the client's outer ear with isopropyl alcohol to remove wax.
- D. Hold the ear dropper 1 cm (0.5 in) from the client's ear.
Correct Answer: D
Rationale: Holding the dropper 1 cm above the ear canal ensures safe, accurate administration without contact.
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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 receive a breast examination from your provider each year after age 30.
- D. You should start performing monthly breast self-examinations at age 35.
Correct Answer: A
Rationale: Guidelines recommend mammograms starting at 40 for average-risk women.
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Apply clean gloves.
- B. Prick the side of the client's finger.
- C. Squeeze the client's finger until a blood drop forms.
- D. Cleanse the client's finger with an iodine swab.
- E. Elevate the client's hand above the level of the heart
Correct Answer: A,B
Rationale: A: Gloves ensure safety. B: Side of finger is less painful and effective for blood collection.
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. Removing the client's dentures from their mouth
- D. Closing the client's eyes
Correct Answer: C
Rationale: Removing dentures alters appearance unnaturally; they should remain unless otherwise specified.
A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?
- A. Rapid chewing
- B. Garbled voice
- C. Sneezing
- D. Increased hunger
Correct Answer: B
Rationale: A garbled voice post-stroke indicates swallowing difficulty, a dysphagia sign.
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. Provide oral care to the client once every 8 hr.
- C. Place the head of the client's bed flat.
- D. Use a fan to circulate air in the client's room.
Correct Answer: D
Rationale: A fan improves air movement, easing dyspnea in end-of-life care.