Nokea
A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?
- A. Oral suction equipment
- B. Tongue depressor
- C. Tracheostomy tray
- D. Wrist restraints
Correct Answer: A
Rationale: Oral suction equipment is correct. During a seizure, there is a risk of aspiration due to the loss of airway control. Oral suction equipment should be readily available in the room to clear the airway if needed, especially if the client experiences a seizure with oral secretions.
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A nurse is reinforcing teaching with a client who is scheduled for a urodynamic study. Which of the following instructions should the nurse include?
- A. Fast for 8 hours before the study.
- B. Avoid urinating before the study.
- C. Expect general anesthesia.
- D. Remove all jewelry before the study.
Correct Answer: B
Rationale: Avoiding urination before a urodynamic study ensures the bladder is full, allowing accurate assessment of bladder function.
A nurse is caring for a client who is receiving oxygen therapy via nasal cannula. Which of the following actions should the nurse take?
- A. Apply petroleum jelly to the nares.
- B. Secure the cannula with tape on the forehead.
- C. Check the nares for irritation.
- D. Increase the flow rate if the client reports dryness.
Correct Answer: C
Rationale: Checking the nares for irritation ensures early detection of skin breakdown from prolonged cannula use.
A nurse is reinforcing teaching with a client who is scheduled for a liver biopsy. Which of the following instructions should the nurse include?
- A. Fast for 8 hours before the procedure.
- B. Expect to stay overnight after the procedure.
- C. Avoid coughing during the procedure.
- D. Take a sedative before the procedure.
Correct Answer: A
Rationale: Fasting for 8 hours before a liver biopsy reduces the risk of complications and ensures a clear procedure field.
A nurse is caring for a client who has a new diagnosis of Raynaud's disease. Which of the following findings should the nurse expect?
- A. Cold fingers
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Cold fingers, often with color changes, are a hallmark symptom of Raynaud's disease due to vasospasm.
A nurse is caring for a client who has a new prescription for digoxin. Which of the following laboratory values should the nurse monitor?
- A. Potassium
- B. Hemoglobin
- C. Cholesterol
- D. Albumin
Correct Answer: A
Rationale: Digoxin toxicity risk increases with hypokalemia, so monitoring potassium levels is critical to ensure safety.