Nokea
An adult client who is ambulating in the corridor with the nurse becomes dizzy and faint. What should the nurse do at this time?
- A. Have her put her head between her legs
- B. Quickly go to get help
- C. Guide her to a chair in the corridor and ease her into it
- D. Encourage the client to walk faster
Correct Answer: C
Rationale: Guiding the client to a chair prevents falls and ensures safety during dizziness. Head positioning, seeking help, or faster walking are unsafe or impractical.
You may also like to solve these questions
A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect?
- A. Black, sticky stools
- B. Greasy, foul-smelling stools
- C. Stools mixed with blood and mucus
- D. Thin, 'ribbon-like' stools
Correct Answer: C
Rationale: Intussusception causes intestinal obstruction, often leading to 'currant jelly' stools (blood and mucus). Black, sticky stools suggest upper GI bleeding. Greasy stools indicate malabsorption. Ribbon-like stools suggest rectal narrowing.
The nurse is caring for a client who had a total thyroidectomy. What should the nurse plan to observe the client for immediately after his return to the nursing care unit?
- A. Hoarseness
- B. Signs of hypercalcemia
- C. Loss of reflexes
- D. Mental confusion
Correct Answer: B
Rationale: Total thyroidectomy risks parathyroid gland damage, leading to hypocalcemia (not hypercalcemia). However, the question likely intends hypocalcemia signs (tetany, spasms), which are critical to monitor immediately post-surgery. Hoarseness, reflexes, or confusion are less urgent.
A client is admitted for treatment of a right upper lobe infiltrate and to rule out tuberculosis. Which of these would be the most appropriate self-protective action by the nurse?
- A. Provide negative room ventilation
- B. Wear a face mask with shield
- C. Wear a particulate respirator mask
- D. Institute airborne precautions
Correct Answer: C
Rationale: Tight fitting, high-efficiency masks are required when caring for clients who have a suspected communicable disease of the airborne variety.
Laboratory reference ranges
Platelets
150,000-400,000/mm3
(150-400 x 10%/L)
The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse clarify with the health care provider?
- A. Clopidogrel for client with history of stroke and platelet count of 154,000/mm² (154 x 10â¹/L)
- B. Losartan for client with hypertension who is 8 weeks pregnant
- C. Prednisone for client with herpes simplex lesions and Bell palsy
- D. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease
Correct Answer: B
Rationale: Losartan is contraindicated in pregnancy due to fetal harm risks. Clopidogrel is safe with normal platelet counts, prednisone is appropriate for Bell palsy, and tiotropium is suitable for COPD despite pneumonia.
The nurse is caring for a bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client?
- A. Consult with the wound care nurse specialist
- B. Insert a rectal tube to contain the feces
- C. Provide perianal skin care with barrier cream
- D. Use incontinence briefs to protect the skin
Correct Answer: C
Rationale: Perianal skin care with barrier cream prevents skin breakdown, a common complication of fecal incontinence. Wound care consultation follows if breakdown occurs. Rectal tubes risk complications, and briefs may trap moisture, worsening irritation.