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An upset client says to the nurse, 'Where did you learn to be a nurse? You don't know anything.' How should the nurse respond?
- A. I'm sorry you feel that way.'
- B. I went to a fine nursing school.'
- C. You sound upset.'
- D. Please don't speak to me that way.'
Correct Answer: C
Rationale: Reflecting the client's emotions ('You sound upset') opens therapeutic dialogue, addressing feelings without defensiveness. Other responses escalate or dismiss.
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A woman is seen in clinic with complaints suggesting cholecystitis or cholelithiasis. What teaching should the nurse expect to reinforce?
- A. Sit up after you eat.
- B. Avoid carbonated beverages.
- C. Avoid caffeine.
- D. Avoid fatty foods.
Correct Answer: D
Rationale: Fatty foods trigger gallbladder contraction, worsening pain in cholecystitis or cholelithiasis; avoiding them reduces symptoms. Sitting up, carbonated drinks, or caffeine are less critical.
The nurse is caring for clients(width)clients in the pediatric clinic.
- A. Which cranial nerve should the nurse assess in an infant with a 'crooked' smile?
- B. III.
- C. V.
- D. VII.
- E. XI.
Correct Answer: C
Rationale: A crooked smile in an infant suggests facial muscle weakness, controlled by the facial nerve (VII), which governs facial expressions. Cranial nerves III (eye movement), V (sensation), and XI (neck/shoulder movement) are unrelated to smiling.
The nurse is caring for a client with a chest tube. On the second postoperative day, the chest tube accidentally disconnects from the drainage tube. The first action the nurse should take is
- A. reconnect the tube
- B. raise the collection chamber above the client's chest
- C. call the health care provider
- D. clamp the chest tube
Correct Answer: D
Rationale: Immediate steps should be taken to prevent air from entering the chest cavity. Lung collapse may occur if air enters the chest cavity. Clamping the tube close to the client's chest is the first action to take, followed by health care provider notification.
The LPN/LVN is making assignments in a long-term care facility. Staff on duty include another LPN and a new certified nursing assistant. Which client can most safely be assigned to the nursing assistant?
- A. Ms. A., 92 years old, has dementia and advancing congestive heart failure (CHF).
- B. Ms. B., 83 years old, has Alzheimer's and Parkinson's and is ambulatory with assistance.
- C. Mr. C., 76 years old, has just been transferred from an acute care facility where he had a total hip replacement four days ago.
- D. Mr. D., 29 years old, had a closed head injury and is in a semi-vegetative state with a tracheostomy and a gastrostomy.
Correct Answer: B
Rationale: Ms. B's ambulatory status with assistance aligns with CNA tasks like hygiene and transfers, safest for a new CNA compared to complex needs.
The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which of the following is the BEST response by the nurse?
- A. 11 months of age.
- B. 14 months of age.
- C. 17 months of age.
- D. 20 months of age.
Correct Answer: D
Rationale: by 24 months may be able to achieve daytime bladder control