Nokea
A patient's hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care?
- A. Adolescent
- B. Preschooler
- C. Older adult
- D. Adult
Correct Answer: B
Rationale: The correct answer is B: Preschooler. Family customs have a significant impact on hygiene practices during childhood, especially in the early years. Preschoolers are at an age where they are learning and forming habits, and family customs play a crucial role in establishing routines such as bathing and brushing teeth. Adolescents, older adults, and adults are more likely to have established their own hygiene routines that may not be as heavily influenced by family customs as in early childhood. Therefore, the nurse is most likely providing care to a preschooler in this scenario.
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A healthcare professional is collecting a urine specimen for a client to test via urine dipstick to determine the urine's specific gravity. The healthcare professional knows the result will indicate the amount of:
- A. Solutes in the urine
- B. Bacteria in the urine
- C. pH level of the urine
- D. Glucose in the urine
Correct Answer: A
Rationale: Specific gravity measures the concentration of solutes in the urine, reflecting the kidney's ability to concentrate or dilute urine. Choice B, bacteria in the urine, is incorrect because specific gravity does not measure bacterial presence. Choice C, pH level of the urine, is incorrect as it refers to the acidity or alkalinity of the urine, not its specific gravity. Choice D, glucose in the urine, is incorrect as specific gravity does not directly measure glucose levels in urine.
A healthcare provider is receiving a prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the healthcare provider clarify?
- A. Dietitian consult
- B. Speech therapy referral
- C. Oral suction at the bedside
- D. Clear liquids
Correct Answer: D
Rationale: The correct answer is D: 'Clear liquids.' Clients with dysphagia following a stroke are at high risk of aspiration, and clear liquids have a higher risk of aspiration compared to thickened liquids. Therefore, the healthcare provider should clarify the prescription for clear liquids and consider recommending thickened liquids instead to reduce the risk of aspiration. Choice A, 'Dietitian consult,' is essential to ensure the client receives appropriate nutrition tailored to their condition. Choice B, 'Speech therapy referral,' is crucial for dysphagia management and rehabilitation. Choice C, 'Oral suction at the bedside,' is a standard intervention to maintain airway patency and is not contraindicated in clients with dysphagia.
While caring for an older adult client who is violent and attempting to disconnect her IV lines, the provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?
- A. Remove the restraints one at a time
- B. Secure the restraints tightly to prevent movement
- C. Check the restraints every hour
- D. Use leather restraints for additional security
Correct Answer: A
Rationale: Removing restraints one at a time is the correct action to take when caring for a client in soft wrist restraints. This approach ensures safety and comfort while still maintaining the necessary restrictions. Choice B is incorrect as securing the restraints tightly can lead to circulatory issues and discomfort. Choice C of checking the restraints every hour is a reasonable action, but it is not the priority when compared to the correct choice of removing the restraints one at a time. Choice D of using leather restraints for additional security is unnecessary and may be more restrictive and uncomfortable for the client.
When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler?
- A. Immediately after exhalation.
- B. During the inhalation.
- C. At the end of three inhalations.
- D. Immediately after inhalation.
Correct Answer: B
Rationale: The correct answer is B: 'During the inhalation.' Administering the medication while inhaling ensures proper delivery to the lungs. Inhaling the medication allows it to reach the lungs effectively for optimal therapeutic benefit. Choices A, C, and D are incorrect because administering the medication after exhalation or at the end of inhalations may result in improper drug delivery and reduced therapeutic effects.
A nurse is preparing an infusion for a client who was hospitalized with deep-vein thrombosis. The orders read: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?
- A. 8 mL/hr
- B. 10 mL/hr
- C. 12 mL/hr
- D. 15 mL/hr
Correct Answer: A
Rationale: To calculate the infusion rate, use the formula: (Desired units/hr / Total units) Volume. In this case, it would be (800 units/hr / 25,000 units) 250 mL = 8 mL/hr. Therefore, the nurse should set the infusion pump at 8 mL/hr. Choice B, 10 mL/hr, is incorrect because it does not match the calculated rate. Choices C and D, 12 mL/hr and 15 mL/hr respectively, are also incorrect as they do not align with the correct calculation based on the provided data.