Nokea
A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply heat to my affected ankle to decrease swelling.
- B. I can bear full weight on my affected ankle.
- C. I can dangle my affected ankle from the edge of the bed.
- D. I will wrap my affected ankle with an elastic bandage.
Correct Answer: D
Rationale: Wrapping with an elastic bandage provides compression to reduce swelling in a grade 2 sprain. Heat increases swelling, full weight-bearing is premature, and dangling worsens edema.
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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 contributing to the plan of care for a client who has influenza. Which of the following interventions should the nurse include in the plan?
- A. Have the client wear a surgical mask during transport.
- B. Wear an N95 mask while providing care to the client.
- C. Administer an influenza immunization to the client.
- D. Place the client in a negative airflow room.
Correct Answer: A
Rationale: A surgical mask during transport prevents droplet spread of influenza. An N95 and negative airflow are for airborne diseases, and immunization isn't given during active infection.
A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?
- A. Elevate the head of the client's bed for 1 hr. after the feeding.
- B. Administer the feeding solution at a cold temperature.
- C. Rotate the jejunostomy tube once per day.
- D. Flush the tube with 90 mL of sterile water before and after the feeding.
Correct Answer: A
Rationale: Elevating the head for 1 hour post-feeding prevents aspiration, a key concern with jejunostomy feedings. Cold solutions, rotation, and excessive flushing aren't standard.
A nurse is assisting with the development of the plan of care for a client who has a low WBC count. Which of the following interventions should the nurse include?
- A. Obtain the client's rectal temperature every 4 hr.
- B. Prohibit fresh flowers in the client's room.
- C. Encourage the client to eat a low-protein diet.
- D. Initiate airborne precautions for the client.
- E. Monitor daily CBC.
- F. Limit visitors.
- G. Use strict hand hygiene.
Correct Answer: B
Rationale: Fresh flowers can harbor bacteria, increasing infection risk in neutropenia; rectal temps risk injury, and airborne isn't needed.
Vital Signs
1000:
Temperature 37° C (98.6° F)
Blood pressure 132/60 mm Hg right arm supine
Blood pressure 118/60 mm Hg right arm sitting
Blood pressure 102/50 mm Hg right arm standing
Heart rate 108/min
Respiratory rate 24/min
Pulse oximetry 94% on room air
Nurses Notes
1100:
Reinforced education about iron supplements and dietary recommendations.
Which of the following instructions should the nurse include? (Client with iron deficiency anemia)
- A. Take an antacid within 30 min after medication
- B. Increase sources of fiber in the diet.
- C. Take the medication with a source of vitamin C
- D. Take the medication on an empty stomach.
- E. Increase intake of milk and dairy products.
- F. Expect immediate energy improvement.
- G. Avoid green leafy vegetables.
Correct Answer: B,C,D
Rationale: Fiber prevents constipation, vitamin C enhances absorption, and empty stomach improves uptake; antacids and dairy reduce absorption.