Nokea
A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?
- A. You will not become fatigued when you use assistive devices.
- B. Plan to hire a home care aid to perform all of your ADLs.
- C. Install grab bars in your shower to assist with your balance.
- D. Place a towel in the shower to prevent slipping.
Correct Answer: C
Rationale: Grab bars support balance and safety, key for CVA clients with ADL challenges. Other options are impractical or unsafe.
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A nurse is preparing to perform a sterile dressing change for a client who has a stage III pressure ulcer. Which of the following actions should the nurse plan to take?
- A. Prepare the sterile dressing supplies 30 min before the dressing change.
- B. Don sterile gloves before removing the dressing,
- C. Disinfect the wound bed with alcohol before applying tape.
- D. Offer the client pain medication before the procedure.
Correct Answer: D
Rationale: Offering pain medication beforehand reduces discomfort during the dressing change for a stage III ulcer. Supplies should be prepared just before, sterile gloves are used after removal, and alcohol isn't used on open wounds.
History and Physical
1000:
Client reports generalized weakness and increased fatigue over the past few months.
Client states they become short of breath after climbing a flight of stairs and are having difficulty keeping up with their grandchildren.
History of rheumatoid arthritis. Reports taking naproxen 500 mg twice a day.
Client reports they follow a vegan diet.
Denies pain or discomfort.
Bilateral breath sounds clear and present throughout.
Mucous membranes pale.
Apical pulse rapid, regular.
Which of the following findings require follow-up? (Client with generalized weakness, vegan diet, pale mucous membranes)
- A. Breath sounds
- B. Activity level
- C. Hematocrit
- D. Blood pressure
- E. Pain level
- F. Temperature
- G. Oxygen saturation
Correct Answer: B,C
Rationale: Decreased activity level and low hematocrit (24%) suggest anemia, requiring follow-up; breath sounds are clear, and other findings are less urgent.
A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dL. Which of the following findings should the nurse identify as an indication of metabolic acidosis?
- A. Tingling of the fingers
- B. Positive Trousseau's sign
- C. Increased respiratory rate
- D. Dizziness upon standing
- E. Hypotension
- F. Muscle weakness
- G. Dry mouth
Correct Answer: C
Rationale: Increased respiratory rate (Kussmaul breathing) compensates for acidosis in diabetic ketoacidosis.
A nurse is reinforcing teaching with a client who has heart failure and a new prescription for furosemide. The nurse should instruct the client to monitor for which of the following adverse effects?
- A. Rhinitis
- B. Metallic taste
- C. Ringing in ears
- D. Agitation
- E. Weight gain
- F. Dry cough
- G. Blurred vision
Correct Answer: C
Rationale: Ringing in ears (tinnitus) is a sign of furosemide ototoxicity; rhinitis and metallic taste aren't typical.
A nurse is reinforcing teaching with the partner of a client who has contact precautions in place for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements by the partner indicates an understanding of the teaching?
- A. I can take my partner outside of the room as long as they wear a mask.
- B. I will wash my hands as soon as I leave the room.
- C. I will wear a gown when I help my partner take a bath.
- D. I will reuse unsoiled gloves when I re-enter the room.
Correct Answer: B
Rationale: Hand washing upon leaving prevents MRSA spread, a key contact precaution. Masks don't suffice, gowns are needed for bathing, and gloves must be fresh each entry.