Nokea
Findings that require immediate follow-up: deep tendon reflexes 4+, generalized weakness, mild leg cramping, heart rate irregular, bowel sounds hyperactive x 4 quadrants
- A. Deep tendon reflexes 4+
- B. Generalized weakness
- C. Mild leg cramping
- D. Heart rate irregular
- E. Bowel sounds hyperactive x 4 quadrants
Correct Answer: A,B,C,D,E
Rationale: A: Hyperreflexia suggests magnesium deficiency. B,C: Weakness and cramping indicate electrolyte issues. D: Irregular heart rate risks arrhythmia. E: Hyperactive bowels may relate to vomiting.
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A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Use a 10-mL syringe filled with cleansing solution.
- B. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
- C. Cleanse the wound with cotton balls.
- D. Dry the wound bed with gauze squares.
Correct Answer: B
Rationale: Holding the syringe 2.5 cm above ensures effective irrigation without contamination.
A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
- A. Calf swelling
- B. Bradycardia
- C. Clammy skin
- D. Tortuous veins
Correct Answer: A
Rationale: Calf swelling is a common sign of deep-vein thrombosis (DVT) and requires immediate reporting due to risk of complications.
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?
- A. Scrub the inside and outside of the inner cannula with a small brush.
- B. Wipe the inside of the inner cannula with a folded pipe cleaner.
- C. Cleanse the stoma site with 0.9% sodium chloride solution.
- D. Unlock and remove the inner cannula.
- E. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
Correct Answer: E,D,A,B,C
Rationale: E: Prepare solution. D: Remove cannula. A: Scrub cannula. B: Wipe cannula. C: Cleanse stoma maintains sterility.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Provide the teaching without expecting the client to respond.
- B. Determine the client's ability to use a communication board
- C. Speak with a loud voice while providing the information.
- D. Avoid the use of facial gestures during the instructions.
Correct Answer: B
Rationale: A communication board aids clients with expressive aphasia in conveying needs, enhancing teaching effectiveness.
A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will clean around the stoma with a moisturizing soap.
- B. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- C. I will cut an opening in the skin barrier that is 1â„2 inch larger than the stoma.
- D. I will apply a thin layer of talc powder around the stoma before placing the appliance.
Correct Answer: B
Rationale: Pressing the skin barrier for 30 seconds ensures adhesion, preventing leakage.