Nokea
A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?
- A. The device requires the client to use upper body strength.
- B. The sides of the sling are for the client to hold on to.
- C. The lower end of the sling goes below the client's calves.
- D. This type of device is useful for a client who cannot assist.
Correct Answer: D
Rationale: A mechanical lift is designed for clients unable to assist, ensuring safe transfer.
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A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- A. Assess the pain level of a client who has received acetaminophen.
- B. Measure the intake and output of a client who has received furosemide.
- C. Check a client's peripheral IV site for redness or swelling.
- D. Reinforce teaching with a client about crutch-gait walking.
Correct Answer: B
Rationale: Measuring intake and output is within the AP's scope; assessment and teaching are nurse responsibilities.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Provide the teaching without expecting the client to respond.
- B. Determine the client's ability to use a communication board.
- C. Speak with a loud voice while providing the information.
- D. Avoid the use of facial gestures during the instructions.
Correct Answer: B
Rationale: A communication board aids clients with expressive aphasia in responding, enhancing understanding.
A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?
- A. Hypocalcemia
- B. Hypermagnesemia
- C. Hyponatremia
- D. Hyperkalemia
Correct Answer: C
Rationale: Hyponatremia occurs from fluid and sodium loss in vomiting and diarrhea.
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?
- A. The stoma is draining a small amount of liquid stool.
- B. The stoma protrudes slightly from the abdomen.
- C. The stoma bleeds lightly when touched.
- D. The stoma appears dark in color.
Correct Answer: D
Rationale: A dark stoma indicates potential necrosis or ischemia, requiring immediate provider attention.
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. Reposition the client once every 4 hr.
- B. Provide oral care to the client once every 8 hr.
- C. Place the head of the client's bed flat.
- D. Use a fan to circulate air in the client's room.
Correct Answer: D
Rationale: A fan improves air movement, easing dyspnea in end-of-life care.