Nokea
A nurse must teach a client how to do wound care and dressing changes prior to discharge. Which of the following are barriers to learning? Select all that apply.
- A. The client is 55 years old.
- B. The client is fearful.
- C. The client is illiterate.
- D. The client is weak and frail.
- E. The client has many questions about the procedures.
- F. The client is hard of hearing.
Correct Answer: B,C,F
Rationale: Barriers to learning include fear (B), which can hinder concentration; illiteracy (C), which affects understanding written instructions; and hearing impairment (F), which impedes verbal communication. Age 55 (A), weakness (D), and asking questions (E) are not barriers.
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A student nurse is assigned to care for a client in a protective environment room. The nurse knows to intervene upon observing which of the following deliveries by the nursing student?
- A. indwelling catheterization kit
- B. flower bouquet
- C. tray of food containing disposable plate and utensils
- D. oral medication
Correct Answer: B
Rationale: Flowers can introduce allergens or pathogens, which are contraindicated in a protective environment. Other items are safe if sterile or disposable.
The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for:
- A. Peaked P wave
- B. Elevated ST segment
- C. Inverted T wave
- D. Prolonged QT interval
Correct Answer: D
Rationale: Quinidine can prolong the QT interval, increasing the risk of torsades de pointes.
Which of the following statements describes Piaget's stage of concrete operations?
- A. Reflex activity proceeds to imitative behavior.
- B. The ability to see another's point of view increases.
- C. Thought processes become more logical and coherent.
- D. The ability to think abstractly leads to logical conclusion.
Correct Answer: C
Rationale: Piaget's concrete operations stage (ages 7-11) is characterized by logical and coherent thought processes, enabling problem-solving with concrete objects.
The nurse is performing fluid resuscitation on a burn client. Which piece of assessment data is the best indicator that it is effective?
- A. Respirations 24, unlabored
- B. Urine output of 30 mL/hr
- C. Capillary refill <4 seconds
- D. Apical pulse of 110/min
Correct Answer: B
Rationale: Urine output of 30-50 mL/hr is the best indicator of adequate fluid resuscitation in burn clients, reflecting sufficient renal perfusion and fluid balance.
A client with Alzheimer's disease has been prescribed donepezil (Aricept). Which information should the nurse include in the teaching plan for a client on Aricept?
- A. Take the medication with meals.'
- B. The medicine can cause dizziness, so rise slowly.'
- C. If a dose is skipped, take two the next time.'
- D. The pill can cause an increase in heart rate.'
Correct Answer: B
Rationale: Donepezil can cause dizziness due to its cholinergic effects, so clients should rise slowly to prevent falls. It's taken at bedtime, not with meals, and doses shouldn't be doubled.