Nokea
Select the 5 actions the nurse should take.
- A. Provide frequent rest periods for the client.
- B. Restrict the client's sodium intake
- C. Advise the client to avoid the use of soap and alcohol-based lotions
- D. Place the client on a low-carbohydrate diet
- E. Place the client under contact isolation.
- F. Instruct the client to avoid blowing their nose forcefully
- G. Assess the client's level of orientation
Correct Answer: A,B,C,E,F,G
Rationale: The correct actions the nurse should take are A, B, C, E, F, and G. A: Providing rest periods promotes healing. B: Restricting sodium intake is crucial for certain health conditions. C: Avoiding soap and alcohol-based lotions can prevent skin irritation. E: Placing the client under contact isolation is necessary to prevent the spread of infection. F: Instructing the client to avoid blowing their nose forcefully prevents injury. G: Assessing the client's level of orientation is essential for monitoring their mental status. Other choices are incorrect because a low-carbohydrate diet (D) is not mentioned, and it is not a priority action in this scenario.
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Which of the following interventions should the nurse include?
- A. Assess the child for frequent swallowing
- B. Carefully suction the child's oropharynx to remove secretions
- C. Administer pancreatic enzymes with meals
- D. Continuously monitor the child's respiratory status
Correct Answer: A
Rationale: Frequent swallowing indicates airway obstruction risks.
Which of the following manifestations should the nurse expect?
- A. Shortness of breath
- B. Dizziness
- C. Epistaxis
- D. Headache
Correct Answer: B
Rationale: Dizziness reflects reduced circulating volume.
The nurse notes that sediment is present in the urine.
- A. Which of the following actions should the nurse take to obtain a sterile urine specimen?
- B. Disconnect the catheter from the collection tubing.
- C. Obtain the specimen from the retention port.
- D. Use the balloon port to obtain the sterile specimen.
- E. Unclamp the collection port below the bag
Correct Answer: B
Rationale: Retention ports allow sterile specimen collection.
For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
- A. Document the blood product transfusion in the client's medical record.
- B. Stay with the client for the first 15 min of the transfusion
- C. Titrate the rate of infusion to maintain the client's blood pressure at least 91/60 mm. Hg
- D. Obtain the first unit of packed RBCS from the blood bank.
- E. Start an IV bolus of lactated Ringers solution.
Correct Answer: A,B,D
Rationale: [A: 1, B: 1, C: 0, D: 1, E: 0, F: , G: ]
- A: Documenting blood product transfusion is crucial for legal and tracking purposes.
- B: Staying with the client ensures immediate response to any adverse reactions.
- C: Titration of infusion rate for BP is not within nursing scope without physician order.
- D: Obtaining packed RBCs precedes transfusion to verify compatibility.
- E: Starting IV bolus of LR is not indicated as it is unrelated to the transfusion process.
Which of the following statements should the nurse make?
- A. We can review some information to help you select a safe alternative practitioner.
- B. I there are therapies available to you, your provider will tell you about them.
- C. Feel free to try whatever therapies that fit within your personal belief system.
- D. I'm sure you can find alternative remedies through an online support group.
Correct Answer: A
Rationale: The correct answer is A because the nurse should offer to review information to assist the patient in selecting a safe alternative practitioner, showing support and guidance. Choice B is incorrect because it assumes the provider will inform the patient of therapies, not necessarily the nurse. Choice C is incorrect as it lacks professional guidance and may lead to unsafe choices. Choice D is incorrect as it suggests the patient can find remedies independently without professional advice.