Nokea
A nursing assistant is providing care to a client with left-sided paralysis. Which of the following actions by the nursing assistant requires the nurse to provide further instruction?
- A. Providing passive range of motion exercises to the left extremities during the bed bath.
- B. Elevating the foot of the bed to reduce edema.
- C. Pulling up the client under the left shoulder when getting out of bed to a chair.
- D. Putting high top tennis shoes on the client after bathing.
Correct Answer: C
Rationale: Pulling under the paralyzed shoulder can cause injury or discomfort. Passive ROM, elevating the bed, and high-top shoes are appropriate for paralysis care.
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A client with malignant pleural effusions is complaining of dyspnea and chest pain. Place the following interventions that the nurse should perform in the correct order of priority.
- A. Administer morphine sulfate 2 mg I.V.
- B. Apply oxygen at 2 L via nasal cannula.
- C. Educate the client in anticipation of a thoracentesis.
- D. Coach the client on deep breathing exercise.
Correct Answer: B,A,C,D
Rationale: Oxygen (B) addresses immediate hypoxia, morphine (A) relieves pain and dyspnea, education for thoracentesis (C) prepares for definitive treatment, and deep breathing (D) supports respiratory function.
During the early phase of burn care the nurse should assess the client for?
- A. Hypernatremia.
- B. Hypomatremia.
- C. Metabolic alkalosis.
- D. Hyperkalemia.
Correct Answer: D
Rationale: In the early phase, cell damage from burns releases potassium, causing hyperkalemia. Sodium levels typically decrease (hyponatremia), and metabolic acidosis is more common due to tissue hypoxia.
Which of the following family members exposed to tuberculosis would be at highest risk for contracting the disease?
- A. 45-year-old mother.
- B. 17-year-old daughter.
- C. 8-year-old son.
- D. 76-year-old grandmother.
Correct Answer: D
Rationale: The elderly (76-year-old grandmother) are at highest risk due to weakened immune systems, increasing susceptibility to tuberculosis infection. Children and younger adults are less vulnerable unless immunocompromised.
Which stone type is associated with acidic urine?
- A. Calcium oxalate.
- B. Uric acid.
- C. Struvite.
- D. Cystine.
Correct Answer: B
Rationale: Uric acid stones form in acidic urine, requiring alkalinization.
A client with disseminated intravascular coagulation develops ventricular microvascular thrombosis. The nurse should assess the client for:
- A. Hemoptysis.
- B. Focal ischemia.
- C. Petechiae.
- D. Hematuria.
Correct Answer: B
Rationale: Microvascular thrombosis in DIC can cause focal ischemia by obstructing small vessels, leading to tissue damage in organs like the kidneys or brain. Hemoptysis, petechiae, and hematuria are related to bleeding, not thrombosis.