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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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Before ambulating the client for the first time, the nurse obtains the client's BP with an automatic BP machine. Which actions should the nurse take first when obtaining a BP reading of 86/56 mm Hg and pulse rate of 64 bpm?
- A. Assess the client for dizziness and feel the temperature of extremities
- B. Obtain a manual BP cuff and machine and retake the client's BP
- C. Elevate the head of the client's bed and assist the client out of bed
- D. Review the medical record and determine the client's normal BP range
Correct Answer: A
Rationale: A: Assessing for hypotension symptoms like dizziness or cold extremities is priority. B: Retaking BP follows assessment. C: Ambulating risks falls with hypotension. D: Reviewing records is secondary.
All of the following are common reasons that nurses are reluctant to delegate except:
- A. lack of self-confidence.
- B. desire to maintain authority.
- C. confidence in subordinates.
- D. getting trapped in the 'I can do it better myself' mindset.
Correct Answer: C
Rationale: If a delegator has confidence in his subordinates and feels that a task will be performed correctly, he is more likely to delegate. Reasons that delegators are reluctant to delegate include their own lack of confidence, fear of losing authority or personal satisfaction, and feeling that the task can only be performed correctly if they do it themselves.
A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?
- A. calcium
- B. magnesium
- C. potassium
- D. sodium chloride
Correct Answer: D
Rationale: Duodenal intestinal fluid is rich in K+, Na+, and bicarbonate. Suctioning to remove excess fluids decreases the client's K+ and Na+ levels.
A nurse is assessing a patient's right lower extremity. The extremity is warm to touch, red and swollen. The patient is also running a low fever. Which of the following conditions would be the most likely cause of the patient's condition?
- A. Herpes
- B. Scleroderma
- C. Dermatitis
- D. Cellulitis
Correct Answer: D
Rationale: Inflammation of cellular tissue associated with a fever most likely indicates cellulitis.
Nonpharmacological pain management involves all of the following except:
- A. hypnosis alone.
- B. psychological care, including support groups.
- C. physical and psychological modalities.
- D. pain-reducing drugs only.
Correct Answer: D
Rationale: All physical and psychosocial therapies can be used concurrently with drugs and other modalities to manage pain. These interventions can be carried out by the nurse with the client and family.