Nokea
For a client requiring total oral care, it is important for the nurse to:
- A. assemble all equipment, assist the client to semi-Fowler's position, and place a towel on his chest.
- B. place client in Fowler's position, prepare the equipment, and tell the client what to do.
- C. assemble all equipment, place the client in a side-lying position, and place a towel under his chin.
- D. use gloves and clean the client's mouth, including the tongue.
Correct Answer: C
Rationale: Assemble all equipment first; place the client in a side-lying position so that fluid can easily flow out or pool in the side of the mouth for suctioning (to prevent aspiration); and then place a towel under the client's chin and a curved basin against the chin. Gloves should be worn.
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Which of these does not need to be included when calculating a client's fluid intake?
- A. ice chips
- B. Jell-O™
- C. pudding
- D. IV fluid from an antibiotic piggyback
Correct Answer: C
Rationale: Pudding is a semi-solid and does not melt at room temperature, so it should not be included in fluid intake calculations.
The nurse is assessing the client who was just admitted to a surgical unit following abdominal surgery. Which assessment finding requires immediate intervention by the nurse?
- A. Nasogastric tube to low intermittent suction has small amounts of dark bloody returns.
- B. Oxygen saturation level is 92%, and oxygen by nasal cannula is set at 2 liters.
- C. The incisional dressing has a 25-cent-piece-sized shadow of new drainage.
- D. The Jackson-Pratt drain is round in shape with 30 mL serosanguineous drainage.
Correct Answer: D
Rationale: D: A round JP drain indicates lost suction, requiring immediate emptying and compression. A: Minor bloody NG returns are normal post-surgery. B: 92% saturation is adequate. C: Small drainage is monitorable.
The hospitalized client is able to stand to use an electronic digital scale for obtaining the client's prescribed daily weight. Which nursing interventions best ensure that the client's daily weight is accurate? Select all that apply.
- A. Ask the client to wear supportive shoes before stepping on the scale
- B. Ensure that the scale is calibrated and “zeroed†before a weight is obtained
- C. Weigh the client by moving the sliding indicator until the scale balances
- D. Weigh the client at different times of the day and then average the weights
- E. Take the weight as soon as the client wakens in the morning and after voiding
Correct Answer: B,E
Rationale: B: Calibration ensures accuracy. E: Weighing post-voiding at the same time daily standardizes results. A: Shoes add weight. C: Sliding indicators are for balance scales. D: Averaging weights reduces accuracy.
As part of the teaching plan for a client with type I diabetes mellitus, the nurse should include that carbohydrate needs might increase when:
- A. an infection is present.
- B. there is an emotional upset.
- C. a large meal is eaten.
- D. active exercise is performed.
Correct Answer: D
Rationale: Active exercise increases insulin sensitivity, thus lowering blood glucose levels. Additional carbohydrates might be needed to balance the usual insulin dose. All of the other choices increase blood glucose levels.
Assessment of a client with a cast should include:
- A. capillary refill, warm toes, no discomfort.
- B. posterior tibial pulses, warm toes.
- C. moist skin essential, pain threshold.
- D. discomfort of the metacarpals.
Correct Answer: A
Rationale: Assessment for adequate circulation is necessary. Signs of impaired circulation include slow capillary refill, cool fingers or toes, and pain.