Nokea
Following a CT scan with contrast medium, the nurse should give attention to:
- A. Maintaining bed rest for 8 hours
- B. Forcing fluids
- C. Observing the puncture site for hemorrhage
- D. Administering pain medication
Correct Answer: B
Rationale: Forcing fluids promotes excretion of contrast medium, reducing risk of renal toxicity. Bed rest and hemorrhage monitoring are not typically required.
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The nurse is caring for an 80-year-old client with Parkinson’s disease.
- A. What is the most realistic and appropriate nursing goal for an 80-year-old client with Parkinson’s disease?
- B. Return the client to usual activities of daily living.
- C. Maintain optimal function within the client’s limitations.
- D. Prepare the client for a peaceful and dignified death.
- E. Arrest progression of the disease process in the client.
Correct Answer: B
Rationale: Parkinson’s disease is progressive and irreversible, so maintaining optimal function within the client’s limitations is the most realistic goal, focusing on mobility, safety, and quality of life. Returning to normal activities, preparing for death, or arresting progression are unrealistic or inappropriate.
An infant who had a repair of a cleft lip and palate. The respiratory assessment reveals that the infant has upper airway congestion and slightly labored respirations.
Which of the following nursing actions would be MOST appropriate?
- A. Elevate the head of the bed.
- B. Suction the infant's mouth and nose.
- C. Position the infant on one side.
- D. Administer oxygen until breathing is easier.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not promote adequate drainage from the upper airways (2) contraindicated based on the infant's operative site (3) correct, will facilitate drainage of mucus from upper airway, and will promote adjustment to breathing through the nose (4) does not relieve the congestion
The nurse is caring for a woman who had a mastectomy following a diagnosis of breast cancer. When the nurse enters the room, the curtains are drawn, and the client is lying with her body turned toward the wall away from the nurse. When the nurse approaches her, the client says, 'Just leave me alone. I'm no use to anyone. I'm not even a real woman.' How should the nurse respond?
- A. Leave the room
- B. Open the curtains
- C. Say, 'You sound upset.'
- D. Say, 'Women are more than breasts.'
Correct Answer: C
Rationale: Acknowledging the client's feelings is an appropriate response to this common grief reaction following the loss of a body part. Leaving the room would reinforce the client's perception that she is useless. Opening the curtains does not address the client's concerns; it merely forces the nurse's perception of appropriateness on the client. Saying 'Women are more than breasts' is not an appropriate response to the client. The nurse should recognize the client's feelings, not put her down.
When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurse knows that which of the following instructions is BEST?
- A. After pursed-lip breathing, cough into a container.
- B. Upon awakening, cough deeply and expectorate into a container.
- C. Save all sputum for three days in a covered container.
- D. After respiratory treatment, expectorate into a container.
Correct Answer: B
Rationale: specimens should be obtained in the early morning because secretions develop during the night
The nurse is to perform a routine blood glucose check on a diabetic client before administering insulin. Which action is correct?
- A. Puncture the end of the thumb in the middle of the fleshy part.
- B. Puncture the end of the finger on the side.
- C. Draw blood from the antecubital vein in the arm.
- D. Puncture the finger and collect the blood in a vial.
Correct Answer: B
Rationale: Puncturing the finger's side avoids nerve-rich areas, ensuring accurate and less painful glucose testing.