Nokea
A recovering alcoholic asked the nurse, 'Will it be ok for me to just drink at special family gatherings?' Which initial response by the nurse would be best?
- A. A recovering person has to be very careful not to lose control, therefore, confine your drinking only to family gatherings.
- B. At your next AA meeting discuss the possibility of limited drinking with your sponsor.
- C. A recovering person needs to get in touch with their feelings. Do you want a drink?
- D. A recovering person cannot return to drinking without starting the addiction process over.
Correct Answer: D
Rationale: A recovering person cannot return to drinking without starting the addiction process over. Total abstinence is required to maintain recovery.
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The nurse is caring for a client with Guillain-Barré syndrome after a recent gastrointestinal illness. Monitoring for which symptom is a nursing care priority in this client?
- A. Diaphoresis with facial flushing
- B. Hypoactive or absent bowel sounds
- C. Inability to cough or lift the head
- D. Warm, tender, and swollen leg
Correct Answer: C
Rationale: Inability to cough or lift the head (C) indicates respiratory muscle weakness, a life-threatening complication in Guillain-Barré syndrome, making it the priority.
The nurse should consider which of the following client reports as an indication of an allergic reaction?
- A. I can't eat broccoli or cabbage when I take my warfarin.'
- B. I get a headache when using my nitroglycerine patch.'
- C. My feet swell when I take felodipine.'
- D. My lips swell when I eat bananas or avocados.'
Correct Answer: D
Rationale: Lip swelling (D) indicates an allergic reaction to food. Broccoli/cabbage (A) affects warfarin's efficacy, headaches (B) are a side effect of nitroglycerin, and swelling (C) is a side effect of felodipine.
The nurse is making assignments for the day's care. Which assignment should not be given to the nursing assistant?
- A. Emptying the Foley catheter bag
- B. Administering a Fleet's enema
- C. Measuring the oral intake
- D. Feeding a client with depression
Correct Answer: B
Rationale: Administering an enema requires nursing judgment and is outside a nursing assistant's scope. Other tasks are appropriate for a nursing assistant.
The nurse is caring for a client who had an endoscopic procedure yesterday to stop upper gastrointestinal bleeding and who started a clear liquid diet today. Which of the following foods would be appropriate to offer to this client? Select all that apply.
- A. Apple juice
- B. Chicken broth
- C. Cranberry juice
- D. Cream of chicken soup
- E. Unsweetened tea
- F. Vanilla ice cream
Correct Answer: A, B, C, E
Rationale: Clear liquids include apple juice (A), chicken broth (B), cranberry juice (C), and unsweetened tea (E). Cream of chicken soup (D) and ice cream (F) are not clear liquids.
Vital signs
Temperature 95 F (35 C)
Blood pressure 90/50 mm Hg
Heart rate 50/min
Respirations 6/min
SpO2 83%
The nurse is caring for a client with hypothyroidism who has become lethargic and difficult to rouse. Which action is the priority?
- A. Administer scheduled PO levothyroxine
- B. Perform bag-valve-mask ventilation
- C. Place a warming blanket on the client
- D. Review client's thyroid laboratory results
Correct Answer: B
Rationale: Lethargy and unresponsiveness in hypothyroidism suggest myxedema coma, requiring immediate airway management with ventilation (B). Levothyroxine (A), warming (C), and lab review (D) are secondary.