Nokea
A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?
- A. Pull the client's pinna downward and back.
- B. Cleanse the client's outer ear with isopropyl alcohol to remove wax.
- C. Hold the ear dropper 1 cm (0.5 in) from the client's ear.
- D. Request the client remain supine for 10 min following administration.
Correct Answer: C
Rationale: Holding the dropper 1 cm away ensures accurate delivery without contaminating the ear canal.
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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. Increased hunger
- B. Garbled voice
- C. Sneezing
- D. Rapid chewing
Correct Answer: B
Rationale: A garbled voice suggests swallowing difficulty, a common dysphagia sign post-stroke.
A nurse is performing a wound irrigation for a client who has methicillin-resistant Staphylococcus aureus. When removing personal protective equipment, which of the following pieces should the nurse remove first?
- A. Gloves
- B. Gown
- C. Goggles
- D. Mask
Correct Answer: A
Rationale: Removing gloves first prevents hand contamination when removing other PPE.
A nurse is preparing to perform a fecal occult blood test of stool specimens for a client. Which of the following actions should the nurse plan to take?
- A. Ensure that the stool specimen does not contain urine.
- B. Wear sterile gloves when handling the stool specimen.
- C. Repeat the test three times using the same stool specimen.
- D. Have the client defecate into a bedpan that contains a small amount of water.
Correct Answer: A
Rationale: Urine contamination can cause false positives, compromising test accuracy.
A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?
- A. Conduct staff communications away from the client's room.
- B. Avoid entering the client's room unless requested during the night.
- C. Turn on the client's TV to distract from hallway noise.
- D. Turn off alarms on bedside monitoring equipment.
Correct Answer: A
Rationale: Reducing noise near the client’s room promotes a sleep-friendly environment.
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. Room number
- B. Medical diagnosis
- C. Age
- D. Photograph
Correct Answer: D
Rationale: A photograph provides a unique, visual confirmation of identity for safe medication administration.