Nokea
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. Provide oral care to the client once every 8 hr.
- B. Use a fan to circulate air in the client's room.
- C. Reposition the client once every 4 hr.
- D. Place the head of the client's bed flat.
Correct Answer: B
Rationale: A fan circulates air, relieving dyspnea by enhancing the feeling of airflow.
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A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, 'I'm not touching that thing.' Which of the following actions should the nurse take?
- A. Ask the client to explain her feelings.
- B. Request that someone from the client's family participate in the care.
- C. Explain why her participation is important.
- D. Tell the client that it is safe to touch her ostomy.
Correct Answer: A
Rationale: Asking about feelings shows empathy and helps address the client’s concerns.
A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?
- A. Overweight
- B. Underweight
- C. Ideal body weight
- D. Obese
Correct Answer: A
Rationale: A BMI of 25-29.9 is categorized as 'overweight.' This indicates that the client is above the ideal weight range but has not reached the threshold for obesity.
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? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 12.5 mL
Rationale: 55 lb = 25 kg; 50 mg/kg/day = 1250 mg/day; 1250 mg / 4 doses = 312.5 mg/dose; 312.5 mg / (125 mg/5 mL) = 12.5 mL/dose.
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.
A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?
- A. Client instructed on self-care needs.
- B. Episiotomy approximated. 3 cm (1.18 in) in length.
- C. Client drank adequate amounts of fluid with meals.
- D. Oral temperature elevated at 0800.
Correct Answer: B
Rationale: Documenting the status of the episiotomy provides essential information regarding healing and recovery, a priority in postpartum care.