Nokea
A patient who has completed detox is ready to start recovery. He or she asks for advice. Which of the following is the best advice to give the patient?
- A. Focus on 1 day at a time. Identify your triggers and learn ways to avoid them.
- B. The goal of recovery is to lengthen periods between relapses.
- C. You will be in recovery all your life.
- D. Ask the practitioner to recommend you to a rehab program.
Correct Answer: A
Rationale: Focusing on daily goals and trigger identification empowers patients to manage their recovery actively.
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What is most important to determine when completing Mr. Anderson’s nursing history?
- A. Known allergy to penicillin
- B. Work habits
- C. History of COPD
- D. Sleep and rest habits
Correct Answer: A
Rationale: Penicillin allergy is critical to know before administering antibiotics.
A patient is diagnosed with Bell's palsy and has signs of unilateral facial paralysis and is unable to close his right eye. What eye care is required?
- A. The patient will need to instill artificial teardrops and use an eye patch.
- B. None, since the symptoms will disappear in a few weeks.
- C. Increase fluid intake to prevent dryness of the eye.
- D. Wear sunglasses.
Correct Answer: A
Rationale: Protecting the exposed eye is crucial in Bell's palsy to prevent corneal damage.
Which action should you delegate to the nursing assistant for the client with diabetic ketoacidosis? (Choose all that apply.)
- A. Check fingerstick glucose every hour
- B. Record intake and output every hour
- C. Check vital signs every 15 minutes
- D. Assess for indicators of fluid imbalance
Correct Answer: A
Rationale: Checking fingerstick glucose and recording intake/output are routine tasks that can be delegated to a nursing assistant. Assessing fluid imbalance and checking vital signs frequently require more skilled nursing judgment.
14. A patient newly diagnosed with type 2 diabetes has been given a prescription to start on an oral hypoglycemic. The patient tells the nurse she would rather control her blood sugar with herbal therapy. Which action should the nurse take?
- A. Advise the patient to discuss using herbal therapy with her physician.
- B. Advise the patient that herbal therapy is not safe and should not be used.
- C. Advise the patient to give the prescriptive medication time to work before using herbal therapy.
- D. Advise the patient that if she takes herbal therapy, she will have to monitor her blood sugar more often.
Correct Answer: A
Rationale: Referring the patient to her physician (option A) ensures that any decision regarding herbal therapy is made collaboratively and safely.
Thirty-six hours postoperatively a patient has a temperature of 100°F (37.8°C). What is the most likely cause of this temperature elevation?
- A. Dehydration
- B. Wound infection
- C. Lung congestion and atelectasis
- D. Normal surgical stress response
Correct Answer: D
Rationale: Low-grade fever within the first 48 hours postoperatively is typically a normal response to surgical stress.