Nokea
A nurse is reinforcing fall-prevention teaching to the spouse of a 78-year-old client who recently experienced a stroke. What suggestion by the nurse is most effective in preventing falls?
- A. Ensure that your spouse rises slowly after sitting or lying down.'
- B. Purchase a walker for your spouse to use when walking around the home'
- C. Remove all area rugs and install grab bars in the bathroom'
- D. Schedule a home health aide to monitor your spouse while you are away.'
Correct Answer: C
Rationale: Removing rugs and installing grab bars (C) directly addresses environmental hazards, the most effective fall prevention strategy. Rising slowly (A), using a walker (B), or hiring an aide (D) are helpful but less comprehensive.
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Which of the following infractions can result in the revocation of the nurse's license?
- A. Failure to render care during a natural disaster
- B. Suspected negligence
- C. A felony conviction
- D. Failure to pay license renewal fees
Correct Answer: C
Rationale: A felony conviction can lead to license revocation due to its impact on professional integrity. Natural disaster response, negligence, or unpaid fees may have other consequences but are less likely to cause revocation.
A client with a panic disorder has a new prescription for Xanax (alprazolam). In teaching the client about the drug's actions and side effects, which of the following should the nurse emphasize?
- A. Short-term relief can be expected
- B. The medication acts as a stimulant
- C. Dosage will be increased as tolerated
Correct Answer: A
Rationale: Short-term relief can be expected. Xanax is a short-acting benzodiazepine useful in controlling panic symptoms quickly.
Laboratory results
Sodium
136-145 mEq/L
(136-145 mmol/L) 126 mEq/L
(126 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 4.8 mEq/L
(4.8 mmol/L)
Calcium
9.0–10.5 mg/dL
(2.25–2.62 mmol/L) 9.0 mg/dL
(2.25 mmol/L)
A client with heart failure has gained 5 lb (2.26 kg) over the last 3 days. The nurse reviews the client's blood laboratory results. Based on this information, what medication administration does the nurse anticipate?
- A. 0.45% sodium chloride IV
- B. Calcium gluconate
- C. Furosemide
- D. Sodium polystyrene sulfonate
Correct Answer: C
Rationale: Weight gain in heart failure suggests fluid retention. Furosemide (C), a diuretic, is anticipated to reduce fluid overload. Sodium chloride (A) worsens fluid retention, and calcium gluconate (B) and sodium polystyrene (D) address other conditions.
The nurse is collecting data from a 10-year-old client during a routine physical examination. Which of the following actions should the nurse take? Select all that apply.
- A. Use correct anatomical terminology while reinforcing teaching about self-care.
- B. Conduct a head-to-toe examination in the same sequence as an adult examination.
- C. Explain the purpose of the examination equipment and any procedures to the client.
- D. Offer the client a gown and allow the client to keep the underwear on during the examination.
- E. Ask the accompanying parent to rate and describe any pain the client may be experiencing.
Correct Answer: A, C, D
Rationale: Using anatomical terminology (A) promotes understanding. Explaining equipment and procedures (C) reduces anxiety. Offering a gown and allowing underwear (D) respects privacy. Adult examination sequences (B) may not suit pediatric needs, and parents rating pain (E) may not accurately reflect the child's experience.
A woman has recently been diagnosed with multiple sclerosis. Which comment by the client indicates that she understands the nature of the disease process?
- A. I understand that recovery will be slow.'
- B. I am faithfully taking the medicines so the symptoms should disappear soon.'
- C. I will avoid being close to my grandchildren until I have been on medication for several months.'
- D. I bought a pretty cane to help me with balance when I am walking.'
Correct Answer: D
Rationale: Using a cane for balance shows understanding of multiple sclerosis' chronic, progressive nature causing mobility issues, unlike expecting full recovery or avoiding grandchildren.