Nokea
A client admitted with acute hypoparathyroidism.
It is MOST important for the nurse to have which of the following items available?
- A. Tracheostomy set.
- B. Cardiac monitor.
- C. IV monitor.
- D. Heating pad.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-tracheostomy set is the most important for the client's safety due to risk for laryngospasm (2) nice to have, but not the most important (3) nice to have, but not the most important (4) unnecessary
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An adult is being worked up for possible pulmonary tuberculosis. The nurse knows that which test is most conclusive for the diagnosis of tuberculosis?
- A. Intradermal skin test
- B. Chest x-ray
- C. Sputum examination
- D. Computed tomography (CT) scan
Correct Answer: C
Rationale: Sputum examination for acid-fast bacilli is the gold standard for confirming tuberculosis, unlike skin tests (screening), x-rays (supportive), or CT (non-specific).
The nurse is caring for a homebound client with a urinary catheter. The client's husband states that he thinks the catheter is obstructed. Which of the following observations would confirm this suspicion?
- A. The nurse notes that the bladder is distended.
- B. The client complains of a constant urge to void.
- C. The nurse notes that the urine is concentrated.
- D. The client complains of a burning sensation.
Correct Answer: A
Rationale: bladder distention is one of the earliest signs of obstructed drainage tubing
Which action by the client indicates an acceptance of his recent amputation?
- A. He verbalizes acceptance.
- B. He looks at the operative site.
- C. He asks for information regarding prosthesis.
- D. He remains silent during dressing changes.
Correct Answer: C
Rationale: Asking about a prosthesis indicates the client is planning for future mobility and adapting to the amputation, a strong sign of acceptance. Verbalizing acceptance is less specific, looking at the site may indicate curiosity or distress, and silence suggests denial or withdrawal.
During an initial interview at an outpatient clinic, a 34-year-old single mother tells the nurse that she has always had difficulty forming relationships and is worried that her 7-year-old daughter will have the same problem. Which of the following statements, if made by the nurse, is BEST?
- A. Children develop trust from birth to 18 months of age.
- B. Children develop trust from 18 months to three years of age.
- C. Children develop trust from three to six years of age.
- D. Children develop trust from six to twelve years of age.
Correct Answer: A
Rationale: Erikson states that trust results from interaction with dependable, predictable primary caretaker
A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. Obtaining a Guthrie Blood Test on a four-day-old infant.
- B. Massaging lotion on the abdomen of a three-year-old diagnosed with Wilm's tumor.
- C. Instructing a five-year-old asthmatic to blow on a pinwheel.
- D. Playing kickball with a 10-year-old with juvenile arthritis (JA).
Correct Answer: B
Rationale: Strategy: 'Would be considered negligence' indicates an incorrect action. (1) obtain after ingestion of protein, no later than 7 days after delivery (2) correct-manipulation of mass may cause dissemination of cancer cells (3) this exercise extends expiratory time and increases expiratory pressure (4) excellent moving and stretching exercise