Nokea
for pain management. When applying a new system, the nurse should:
- A. Press the system in place for 30 to 60 seconds.
- B. Choose a site on the lower torso.
- C. Shave the application site before use.
- D. Apply the system immediately after removal from a package.
Correct Answer: A
Rationale: Rationale:
A: Pressing the system in place for 30 to 60 seconds helps ensure proper adhesion and absorption of the medication. This step is crucial for the effectiveness of the pain management system.
B: Choosing a site on the lower torso is not necessary for applying the system. The site selection should be based on guidelines and patient preference.
C: Shaving the application site is not recommended unless specifically indicated. It is not a standard step for applying a pain management system.
D: Applying the system immediately after removal from a package may not allow the adhesive to fully activate, affecting its efficacy. It is important to follow the recommended steps for proper application.
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An adult is on a clear liquid diet. Which food item can be offered/
- A. Milk
- B. Orange juice
- C. Jello
- D. Ice cream
Correct Answer: C
Rationale: The correct answer is C: Jello. A clear liquid diet includes transparent liquids that do not contain any solid particles, providing easily digestible nutrients. Jello meets these criteria as it is a clear, gelatin-based dessert that melts into a liquid form at room temperature.
Rationale:
1. Jello is a clear liquid that does not contain solid particles, making it suitable for a clear liquid diet.
2. Milk (A) and ice cream (D) are not considered clear liquids as they contain fats and proteins, which are not allowed on a clear liquid diet.
3. Orange juice (B) contains pulp and fibers, making it unsuitable for a clear liquid diet.
Summary:
Jello is the correct choice because it meets the criteria of being a clear liquid without solid particles. Milk, orange juice, and ice cream are not appropriate choices for a clear liquid diet due to their composition.
A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. The ff. nursing interventions might be recommended to help prevent aspiration during eating except:
- A. Provide clear liquids only until the patient can swallow solid foods.
- B. Have the patient swallow twice after each bite
- C. Place food on the unaffected side of the patient’s mouth
- D. Check if the patient’s mouth for pocketing of food
Correct Answer: A
Rationale: The correct answer is A because providing clear liquids only until the patient can swallow solid foods is not a recommended nursing intervention to prevent aspiration. Clear liquids do not require the same level of swallowing coordination as solid foods, so it may not help improve swallowing ability.
B: Having the patient swallow twice after each bite can help clear the throat and reduce the risk of aspiration.
C: Placing food on the unaffected side of the mouth can help direct the food towards the stronger side for swallowing.
D: Checking the patient's mouth for pocketing of food is important to ensure that food is not being retained in the mouth, which could lead to aspiration.
The nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare to absorption at other sites?
- A. Insulin is absorbed more slowly at abdominal injection sites than at other sites.
- B. Insulin absorbed rapidly regardless of the injection site.
- C. Insulin is absorbed more rapidly at abdominal injection than at other sites.
- D. Insulin is absorbed unpredictably at all injection sites.
Correct Answer: C
Rationale: Rationale:
1. Abdominal injection sites have a higher blood supply, leading to faster absorption.
2. Insulin absorption is faster in areas with more blood vessels.
3. Rapid absorption at the abdomen results in quicker onset of action.
4. Other sites may have slower absorption due to less blood flow.
Summary:
A: Incorrect. Absorption is faster at abdominal sites due to increased blood flow.
B: Incorrect. Absorption varies based on injection site blood supply.
C: Correct. Abdominal injection sites have rapid insulin absorption.
D: Incorrect. Insulin absorption is consistent based on blood flow at injection sites.
Which of the ff interventions is implemented for a client with empyema?
- A. Teach the client breathing exercises
- B. Offer assurance that empyema takes less time to resolve
- C. Recommend that the client eat a balanced but light diet
- D. Emphasize the completion of the entire course of drug therapy
Correct Answer: D
Rationale: The correct answer is D: Emphasize the completion of the entire course of drug therapy. Empyema is a serious condition that requires antibiotic treatment. Emphasizing the completion of the entire course of drug therapy is crucial to ensure that the infection is completely eradicated and to prevent the development of drug-resistant strains. Teaching breathing exercises (choice A) may help improve lung function but is not the primary intervention for empyema. Offering assurance that empyema takes less time to resolve (choice B) is incorrect as it can mislead the client about the seriousness of the condition. Recommending a balanced but light diet (choice C) may be beneficial for overall health but is not directly related to treating empyema.
What is the best initial action for the nurse to take?
- A. Try to have the client breathe slower or
- B. Give O2 via nasal cannula
- C. Administer sodium bicarbonate
- D. Monitor the client’s fluid balance
Correct Answer: A
Rationale: The correct initial action for the nurse to take is A: Try to have the client breathe slower. This is because the client may be experiencing respiratory distress, and slowing down their breathing can help improve oxygenation. Giving O2 via nasal cannula (B) should be considered if the client's oxygen saturation is low after trying to slow down their breathing. Administering sodium bicarbonate (C) is not the appropriate initial action unless the client is experiencing severe acidosis. Monitoring the client's fluid balance (D) is important but not the best initial action in this scenario where respiratory distress is the concern.