Nokea
A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?
- A. Cleanse the client's outer ear with isopropyl alcohol to remove wax.
- B. Pull the client's pinna downward and back.
- 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 above prevents contamination and ensures proper delivery.
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A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)
- A. A client reports being dissatisfied with the temperature of the meals provided.
- B. A client receives burns from a heating pad.
- C. A client becomes disoriented and falls out of bed.
- D. A client is unable to afford the physical therapy that the provider recommends.
- E. A client's visitor becomes dizzy and faints in the client's room.
Correct Answer: B,C,E
Rationale: B: Burns indicate harm. C: Falls require reporting. E: Visitor fainting is an unexpected event.
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 assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?
- A. Determine if the client has a support system.
- B. Schedule a mental health consult for the client.
- C. Provide the client with information about coping strategies.
- D. Encourage the client to attend a support group.
Correct Answer: A
Rationale: Assessing the support system first identifies resources to address ineffective coping.
A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?
- A. Unequal height of the shoulders
- B. Expansion of the upper intercostal spaces
- C. Increased convex curve of the cervical spine
- D. Increased concave curve of the thoracic spine
Correct Answer: A
Rationale: Unequal shoulder height is a classic sign of scoliosis due to spinal curvature.
A nurse is contributing to planning an interprofessional conference for a client who reports concerns about their BMI of 30. Which of the following members of the interprofessional team should the nurse include?
- A. Occupational therapist
- B. Pharmacist
- C. Dietician
- D. Spiritual support personnel
Correct Answer: C
Rationale: A dietician addresses BMI concerns through nutritional planning.