Nokea
An 80-year-old woman is having difficulty sleeping. Which nursing action is most appropriate initially?
- A. Ask the physician for an order for a sleeping medication.
- B. Encourage the client to do mild exercises a half hour before going to bed.
- C. Suggest to the client that she not nap during the day.
- D. Recommend the client drink coffee in the evening.
Correct Answer: C
Rationale: Avoiding daytime naps improves nighttime sleep hygiene, a non-pharmacologic initial approach suitable for an elderly client.
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The nurse is reviewing the medical record of a 4-year-old client with failure to thrive. Which of the following risk factors likely contribute to the client's condition? Select all that apply.
- A. Child is the youngest of four children in the home
- B. One parent is incarcerated for spousal abuse
- C. One parent was diagnosed with anorexia nervosa prior to having children
- D. One parent works a full-time job outside the home
- E. Parents are concerned about not having enough money to buy food
Correct Answer: B,C,E
Rationale: FTT risk factors include parental incarceration causing family stress, a history of anorexia nervosa affecting feeding practices, and food insecurity . Being the youngest or a working parent are not direct risks.
It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of these illustrate appropriate assignment instructions for the licensed practical nurse (LPN) to give the UAP? Select all that apply.
- A. Elevate the right leg on two pillows.'
- B. Measure client for compression stockings.'
- C. Please let me know what the urine looks like.'
- D. Tell me what the client eats at lunch.'
- E. Verify wrist restraints are on correctly.'
Correct Answer: A,C,D
Rationale: Appropriate UAP tasks include elevating a leg , observing urine appearance , and reporting food intake . Measuring for stockings and verifying restraints require nursing judgment.
The nurse is caring for a client who is in the first stage of labor and is reporting intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which of the following actions should the nurse take?
- A. Place the client in the supine position
- B. Apply counterpressure to the client's sacrum during contractions
- C. Encourage the client to remain in bed
- D. Request that the nurse anesthetist administer epidural anesthesia
Correct Answer: B
Rationale: For back pain in labor with a right occiput posterior position, applying counterpressure to the sacrum relieves discomfort. Supine position worsens pain, bed rest limits mobility, and epidural is not the first intervention.
The nurse in the outpatient clinic is caring for a client with heart failure who reports increased ankle swelling and a 3-lb (1.4-kg) weight gain over the past 2 days. The nurse reviews the client's current medications and anticipates the need for an increase in the dosage of which of the following medications?
- A. Bumetanide
- B. Candesartan
- C. Carvedilol
- D. Isosorbide
Correct Answer: A
Rationale: A 3-lb weight gain and ankle swelling in heart failure indicate fluid retention, requiring an increased dose of a diuretic like bumetanide . Candesartan , carvedilol , and isosorbide manage other aspects but do not directly address acute fluid overload.
The postoperative client on hydrocodone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client?
- A. Client's respiratory status 60 minutes later
- B. Documenting the client's hypoxic event
- C. Obtaining an order for a different analgesic
- D. Potential for drug-drug interaction now
Correct Answer: A
Rationale: After naloxone administration for opioid-induced hypoxia, monitoring respiratory status is critical as naloxone's effects are short-acting, and respiratory depression may recur. Documentation is important but secondary, changing analgesics is not immediate, and drug interactions are less urgent.