Nokea
Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?
- A. Ask an unlicensed assistive personnel to stay with the client.
- B. Place the bedpan within the reach of the client.
- C. Obtain a bedside commode for the client to use.
- D. Notify the healthcare provider of the client's concerns.
Correct Answer: C
Rationale: Commode prevents enema expulsion accidents.
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The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?
- A. White blood cell count.
- B. Serum sodium levels.
- C. Serum potassium levels.
- D. Creatinine clearance.
Correct Answer: B
Rationale: Excess water dilutes sodium, risking hyponatremia.
The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?
- A. Leave the dressing off until consulting with the healthcare provider.
- B. Apply a hydrocolloidal gel dressing.
- C. Replace the gauze with a transparent dressing.
- D. Increase the frequency of the dressing changes.
Correct Answer: B
Rationale: Hydrocolloidal dressing promotes healing in granulating wounds.
The healthcare provider prescribes cefixime oral suspension 200 mg by mouth twice a day for an older adult who has difficulty swallowing pills. The bottle is labeled, 'Cefixime for Oral Suspension, USP 100 mg per 5 mL.' How many mL should the nurse administer daily? (Enter numerical value only.)
Correct Answer: 20
Rationale: 200 mg/dose × 2 doses = 400 mg/day; 400 mg ÷ (100 mg/5 mL) = 20 mL/day.
The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? Select all that apply.
- A. Hand tremors.
- B. Shuffling gait.
- C. Urinary incontinence.
- D. Diminished visual acuity.
- E. Syncope when bending.
Correct Answer: A,B,D
Rationale: Tremors, gait issues, and poor vision impair safe foot care.
The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?
- A. Develop self-awareness of the nurse's personal values to avoid imposing these values on the client.
- B. Challenge members of the healthcare team whose opinions differ from the wishes of the client.
- C. Educate the client about current nursing literature findings related to the client's ethical dilemma.
- D. Listen to the ethics committee discussions and then inform the client what actions should be taken.
Correct Answer: A
Rationale: Self-awareness prevents bias in advocacy.