Nokea
A nurse is teaching a class about sleep disorders. The nurse should include that which of the following conditions can cause obstructive sleep apnea (OSA)?
- A. Heart failure
- B. Brainstem injury
- C. Recent weight loss
- D. Enlarged tonsils
Correct Answer: D
Rationale: The correct answer is D: Enlarged tonsils. Enlarged tonsils can physically obstruct the airway during sleep, leading to obstructive sleep apnea (OSA). This obstruction causes pauses in breathing during sleep, resulting in disrupted sleep patterns and decreased oxygen levels in the blood. Heart failure (A) is incorrect because it is not a direct cause of OSA. Brainstem injury (B) may disrupt the sleep-wake cycle but is not a common cause of OSA. Recent weight loss (C) can actually improve OSA symptoms by reducing the amount of tissue in the airway. Therefore, the most likely condition to cause OSA among the choices given is enlarged tonsils.
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A nurse is teaching a client about the Rinne test. Which of the following client statements indicates an understanding of the teaching?
- A. I will wear earphones during this test
- B. A small probe is placed inside my ear
- C. A tuning fork is placed on my head
- D. Small electrodes are placed on my scalp
Correct Answer: C
Rationale: The correct answer is C: A tuning fork is placed on my head. In the Rinne test, a tuning fork is first placed against the client's mastoid bone behind the ear and then moved near the ear canal. The client should hear the sound louder when the fork is near the ear if the test is normal. Choice A is incorrect because earphones are not used in the Rinne test. Choice B is incorrect as a probe is not inserted into the ear. Choice D is incorrect as electrodes are not part of the Rinne test. Placing a tuning fork on the head is the correct step in performing the Rinne test to assess hearing conduction.
A nurse in a public clinic is planning a health fair for older adult clients in the community. In teaching medication safety, which of the following foods should the nurse advise the clients to avoid when taking their prescriptions?
- A. Orange juice
- B. Grapefruit juice
- C. Milk
- D. Carbonated beverage
Correct Answer: B
Rationale: The correct answer is B: Grapefruit juice. Grapefruit juice can interact with many medications by inhibiting the enzyme that metabolizes the drugs, leading to higher drug levels in the body and potentially causing adverse effects. Orange juice (A), milk (C), and carbonated beverages (D) do not have significant interactions with most medications. It is important for the nurse to advise older adult clients to avoid grapefruit juice to prevent medication interactions and ensure their safety.
A nurse is preparing to lift a heavy object. Which of the following actions by the nurse indicates understanding of body mechanics?
- A. They bend at the hip when lifting
- B. They keep their feet together when lifting an object
- C. They stand close to the object being moved
- D. They twist their spine when lifting
Correct Answer: C
Rationale: The correct answer is C: They stand close to the object being moved. This action indicates understanding of body mechanics as it reduces the strain on the back by keeping the load close to the body's center of gravity. Standing close to the object allows for better leverage and control during the lift, minimizing the risk of injury.
Rationale for why other choices are incorrect:
A: Bending at the hip when lifting can put excessive strain on the lower back.
B: Keeping feet together may lead to instability and lack of balance during lifting.
D: Twisting the spine when lifting can result in spinal injuries and muscle strain.
A nurse is taking care of a patient that has a new prescription for labetalol (beta blocker). What adverse effect should the nurse include in the medication education?
- A. Hypokalemia
- B. Bleeding
- C. Bradycardia
- D. Seizures
Correct Answer: C
Rationale: The correct answer is C: Bradycardia. Labetalol is a beta blocker that slows down the heart rate by blocking beta-adrenergic receptors. This can lead to bradycardia, which is a slow heart rate. The nurse should educate the patient about this potential adverse effect to prevent any complications.
Hypokalemia (choice A) is not a common adverse effect of labetalol. Bleeding (choice B) is not directly associated with beta blockers like labetalol. Seizures (choice D) are not a typical adverse effect of labetalol. Therefore, the correct answer is C as it directly correlates with the mechanism of action of labetalol.
A nurse opens a unit-dose of a prescribed medication prior to administering it to a client. After education, the client refuses to take the medication. Which of the following actions should the nurse take?
- A. Notify the facility’s ethics committee
- B. Return the opened medication to the medication cart
- C. Report the incident to the provider
- D. Fill out an incident report
Correct Answer: C
Rationale: The correct answer is C: Report the incident to the provider. The nurse should report the client's refusal to take the medication to the provider to ensure appropriate documentation and follow-up care. This step is crucial for the client's safety and well-being.
A: Notifying the ethics committee is not necessary in this situation as the provider should be the first point of contact.
B: Returning the opened medication to the cart is inappropriate and unsafe as it could lead to medication errors.
D: Filling out an incident report may be necessary, but reporting to the provider should be the immediate action.
In summary, option C is the correct choice as it prioritizes the client's care and ensures proper communication with the healthcare provider.