Nokea
In addition to assessing the degree of the client’s impairment, which of the following information should a nurse obtain from a client who has recently turned blind?
- A. About the client’s diet
- B. About the client’s allergy history
- C. About the client’s family’s medical history
- D. About how the client is coping with the visual problems
Correct Answer: D
Rationale: Understanding the client's emotional and psychological state is crucial for providing holistic care.
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For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation been found to be an appropriate intervention (select all that apply)?
- A. Impaired skin integrity related to incision
- B. Impaired mobility related to decreased muscle strength
- C. Risk for aspiration related to decreased muscle strength
- D. Ineffective airway clearance related to decreased respiratory excursion
Correct Answer: D
Rationale: Ambulation addresses multiple postoperative issues, including mobility, respiratory function, constipation, and thromboembolism prevention.
Which nursing interventions should not be delegated to unlicensed assistive personnel (UAP) but should be performed by the RN (select all that apply)?
- A. Administering patient medications
- B. Ambulating stable patients
- C. Performing patient assessment
- D. Evaluating the effectiveness of patient care
Correct Answer: A
Rationale: Medication administration, assessment, evaluation, and teaching require the RN's specialized knowledge and accountability.
A client is being treated for inhalational anthrax following bioterrorism exposure. Which of the following medications should NOT be expected as a common treatment for anthrax?
- A. Ciprofloxacin
- B. Doxycycline
- C. Amoxicillin
- D. Penicillin G
Correct Answer: D
Rationale: The correct answer is D, Penicillin G. Anthrax is caused by Bacillus anthracis, which is susceptible to ciprofloxacin and doxycycline. Penicillin and amoxicillin are not recommended due to the potential for B. anthracis to produce beta-lactamase, which can make the bacteria resistant to penicillin-based medications. Penicillin G is not effective in treating anthrax and should not be expected as a common treatment option.
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
- A. Call the health care provider.
- B. Check vital signs.
- C. Position in high Fowler's.
- D. Administer oxygen.
Correct Answer: D
Rationale: Oxygen administration is immediate to address hypoxemia.
What should a nurse include in the teaching plan for clients who have a potential for hypovolemia?
- A. Avoid alcohol and caffeine
- B. Increase intake of dried peas and beans
- C. Increase intake of milk and dairy products
- D. Avoid table salt or food containing sodium
Correct Answer: A
Rationale: Alcohol and caffeine are diuretics, increasing fluid loss and worsening hypovolemi Avoiding them helps maintain fluid balance.