Nokea
On a home visit, you notice some dust on a vent in your client's room and on the windowsill. Which of the following methods would you teach the family to use for removing dust?
- A. Use a damp cloth to remove the dust.
- B. Use a feather duster to remove dust.
- C. Vacuum up the dust.
- D. Use a broom covered with a cloth.
Correct Answer: A
Rationale: Teaching the family to use a damp cloth removes dust effectively, trapping particles rather than dispersing them, unlike feather dusters or brooms. Vacuuming works but isn't always practical for small areas. This method reduces allergens and infection risks in the home, a simple, accessible nursing intervention for environmental hygiene.
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During a teaching session on dietary management for heart failure, a client makes a statement. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of foods high in sodium.
- B. I should increase my intake of foods high in potassium.
- C. I should decrease my intake of fluids.
- D. I should decrease my intake of fiber.
Correct Answer: C
Rationale: The correct answer is C because decreasing fluid intake is essential in managing fluid retention and symptoms of heart failure. Restricting fluids helps prevent excessive fluid buildup in the body, thus reducing the workload on the heart and alleviating symptoms like swelling and shortness of breath. Choices A, B, and D are incorrect. Increasing intake of foods high in sodium can exacerbate fluid retention and worsen heart failure symptoms. Increasing potassium-rich foods is beneficial for some heart conditions but not heart failure specifically. Decreasing fiber intake is not a standard recommendation for heart failure management.
The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions, which include:
- A. Increased appetite
- B. Elevated liver enzymes
- C. Hypotension
- D. Improved short-term memory
Correct Answer: B
Rationale: Elevated liver enzymes are a key adverse reaction to Cognex, requiring monitoring in dementia appetite, BP, and memory aren't primary concerns. Nurses check LFTs, ensuring safety, critical for managing Alzheimer's medication risks.
A client with a traumatic brain injury is receiving mannitol. The nurse should monitor for which adverse effect of this medication?
- A. Hypotension
- B. Hyperkalemia
- C. Hyperglycemia
- D. Bradycardia
Correct Answer: A
Rationale: Mannitol, an osmotic diuretic, can cause hypotension (A) from fluid shifts and diuresis. Hyperkalemia (B), hyperglycemia (C), or bradycardia (D) are less common. A is correct. Rationale: BP drop risks perfusion; monitoring ensures safety, per pharmacology, critical in brain injury management.
The physician has ordered Stadol (butorphanol) for a post-operative client. The nurse knows that the medication is having its intended effect if the client:
- A. Is asleep 30 minutes after the injection
- B. Asks for extra servings on his meal tray
- C. Has an increased urinary output
- D. States that he is feeling less nauseated
Correct Answer: A
Rationale: Being asleep 30 minutes post-Stadol indicates effective pain relief and sedation, its intended effect post-op extra food, urine output, or less nausea aren't primary goals. Nurses monitor response, ensuring rest and pain control, critical for recovery in surgical care.
The nurse refused to perform a procedure she is not trained to do. This is an example of?
- A. Accountability
- B. Responsibility
- C. Negligence
- D. Malpractice
Correct Answer: B
Rationale: Refusing an untrained procedure is responsibility (B) knowing limits, per duty. Accountability (A) owns actions, negligence (C) and malpractice (D) imply error. B ensures safe practice, making it correct.