Nokea
For which condition would the use of salt tablets be considered?
- A. Mild deficits of serum sodium
- B. Severe deficits of serum magnesium
- C. Severe deficits of serum potassium
- D. Severe deficits of serum calcium
Correct Answer: A
Rationale: Salt tablets are used to correct mild sodium deficits by providing additional sodium chloride.
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What information should be immediately reported to the physician?
- A. The ingested children's chewable vitamins contain iron
- B. The child has been treated several times for ingestion of toxic substances
- C. The child has been treated several times for accidental injuries
- D. The child was nauseated and vomited once at home
Correct Answer: A
Rationale: Iron ingestion can cause severe toxicity and requires immediate medical attention.
A client is 12 hours postoperative and has a chest tube to a disposable water-seal drainage system with suction. The healthcare provider should intervene for which of the following observations?
- A. Constant bubbling in the suction-control chamber
- B. Continuous bubbling in the water-seal chamber
- C. Bloody drainage in the collection chamber
- D. Fluid-level fluctuations in the water-seal chamber
Correct Answer: B
Rationale: The correct answer is B: Continuous bubbling in the water-seal chamber. Continuous bubbling in the water-seal chamber indicates an air leak in the system, which can lead to lung collapse. The water-seal chamber should have intermittent bubbling during exhalation but should not bubble continuously. Constant bubbling in the suction-control chamber (A) is expected and indicates proper suction is being applied. Bloody drainage in the collection chamber (C) is common in the immediate postoperative period. Fluid-level fluctuations in the water-seal chamber (D) can be normal due to changes in intrathoracic pressure.
A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?
- A. S3 heart sound.
- B. Thready pulse.
- C. Flattened neck veins.
- D. Hypoventilation.
Correct Answer: A
Rationale: An S3 heart sound indicates volume overload.
For a client who has sustained recent blindness, which task(s) would be appropriate to delegate to the nursing assistant? (Choose all that apply.)
- A. Listen to the client express grief or loss.
- B. Assist client to ambulate in hall.
- C. Orient client to surroundings.
- D. Encourage independence.
Correct Answer: B
Rationale: Assisting with mobility is within the scope of practice for nursing assistants and ensures safety for the client.
Mrs. Williams asks what “presbyopia†means. The best response would be that Mrs. Williams
- A. is 'farsighted' and can see well at a distance, but her near vision is poor
- B. is 'nearsighted' and can see well when objects are close but cannot see well at a distance
- C. has distorted vision which is caused by a curvature in the eye
- D. has difficulty seeing objects that are very close because her lens is less elastic
Correct Answer: D
Rationale: Presbyopia results from decreased elasticity of the eye's lens, impairing the ability to focus on nearby objects, typically occurring with age.