Nokea
An older adult takes two 81 mg aspirin tablets daily to prevent a heart attack. The client reports having a constant 'ringing' in both ears. How should the nurse respond to the client's comment?
- A. Tell the client that 'ringing' in the ears is associated with the aging process.
- B. Refer the client to have a hearing test.
- C. Schedule the client for audiometric testing.
- D. Explain to the client that the 'ringing' may be related to the aspirin.
Correct Answer: D
Rationale: Aspirin, even at low doses, can cause tinnitus (ringing in the ears) as a side effect. The nurse should explain this potential link and advise consulting the physician.
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The nurse finds it difficult to relieve a client's pain satisfactorily. Which of the following measures should the nurse take next when continuing efforts to promote comfort?
- A. Improve the nurse-client relationship.
- B. Enlist the help of the client's family.
- C. Allow the client additional time to work through his or her own responses to pain.
- D. Arrange to have the client share a room with a client who has little pain.
Correct Answer: A
Rationale: Improving the nurse-client relationship fosters trust, enhancing pain management through better communication and tailored interventions. Family help, time, or room sharing are less direct solutions.
The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. Which of the following steps should be included? Select all that apply.
- A. Splint or support the incision to promote maximal comfort.
- B. Inhale slowly through the nostrils; exhale through pursed lips.
- C. Hold the breath for about 5 seconds to expand the alveoli.
- D. Repeat this breathing method 5 to 10 times hourly.
- E. Close one nostril while inhaling.
Correct Answer: A,B,C,D
Rationale: Splinting the incision (A), slow nasal inhalation with pursed-lip exhalation (B), holding the breath (C), and repeating 5-10 times hourly (D) are correct steps for deep-breathing exercises to prevent atelectasis. Closing one nostril (E) is not part of this technique.
The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can:
- A. Perform the procedure safely and correctly.
- B. Critique the nurse's performance of the procedure.
- C. Explain all steps of the procedure correctly.
- D. Correctly answer a posttest about the procedure.
Correct Answer: A
Rationale: The ability to perform the insulin injection safely and correctly demonstrates mastery of the skill, which is the best indicator of learning.
What action should this nurse take to avoid spreading nosocomial infections?
- A. Remove the face mask.
- B. Remove the hair covering.
- C. Wash her hands before tying the strings on the mask.
- D. Tie the dangling strings of the mask around her neck.
Correct Answer: C
Rationale: Hand hygiene is critical to prevent nosocomial infections. Washing hands before handling the mask ensures the nurse does not contaminate it or transfer pathogens. Removing protective gear or tying strings improperly could increase infection risk.
Because a client's renal stone was found to be composed of uric acid, a low-purine, alkaline-ash diet was ordered. Incorporation of which of the following food items into the home diet would indicate that the client understands the necessary diet modifications?
- A. Milk, apples, tomatoes, and corn.
- B. Eggs, spinach, dried peas, and gravy.
- C. Salmon, chicken, and asparagus.
- D. Grapes, corn, cereals, and liver.
Correct Answer: A
Rationale: Milk, apples, tomatoes, and corn are low-purine and promote an alkaline-ash diet, suitable for uric acid stone prevention.