Nokea
As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following?
- A. What and how much the client drinks, according to family and friends
- B. The blood alcohol level of the client
- C. The blood pressure level of the client
- D. The blood glucose level of the client
Correct Answer: B
Rationale: Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.
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The nurse is observing a certified nursing assistant move a client. Which action, if observed, indicates that the nursing assistant needs more instruction?
- A. The assistant stands with feet spread apart.
- B. The assistant bends from the waist.
- C. The assistant turns her whole body.
- D. The assistant keeps her back straight.
Correct Answer: B
Rationale: Bending from the waist strains the back, indicating improper technique. Wide stance, whole-body turning, and straight back are correct for safe client movement.
The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should
- A. Review the medications the client is receiving
- B. Increase the formula infusion rate
- C. Increase the amount of water used to flush the tube
- D. Attach a rectal bag to protect the skin
Correct Answer: A
Rationale: Review the medications the client is receiving. Medications like antibiotics can cause diarrhea, requiring evaluation.
A client with a history of renal calculi passes a stone made up of calcium oxalate. Which of the following diet instructions should be given to the client?
- A. Increase intake of meats, eggs, fish, plums, and cranberries.
- B. Avoid citrus fruits and juices.
- C. Avoid dark green, leafy vegetables.
- D. Increase intake of dairy products.
Correct Answer: C
Rationale: Dark green, leafy vegetables are high in oxalates, which contribute to calcium oxalate stones. Meats and dairy increase other stone types, and citrus juices are beneficial.
A client with a fracture of the radius had a plaster cast applied 2 days ago. The client complains of constant pain and swelling of the fingers. The first action of the nurse should be
- A. elevate the arm no higher than heart level
- B. remove the cast
- C. assess capillary refill of the exposed hand and fingers
- D. apply a warm soak to the hand
Correct Answer: C
Rationale: A deterioration in neurovascular status indicates the development of compartment syndrome (elevated tissue pressure within a confined area) which requires immediate pressure-reducing interventions.
The mother of a 1-week-old infant says to the nurse, 'When will that ugly black cord thing come off?' How should the nurse reply?
- A. Are you wiping it with alcohol each time you change the baby's diaper?'
- B. It usually comes off in 10 days to three weeks.'
- C. It sounds as if it bothers you. Would you like to talk about it?'
- D. It should be off by now. I'll have the doctor check to be sure there is no problem.'
Correct Answer: B
Rationale: The umbilical cord typically detaches in 10 days to 3 weeks, providing accurate information. Other responses are irrelevant or incorrect.