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The 11:00 AM routine fingerstick (glucose monitoring) test for a client was assigned to the unlicensed assistive personnel by the nurse. At 11:15 AM, the client tells the nurse that no one checked the blood level. The nurse should take what action first?
- A. Ask the unlicensed assistive personnel (UAP) about the situation
- B. Inform the nurse manager
- C. Perform the test
- D. Review the fingerstick procedure with the UAP
Correct Answer: C
Rationale: Performing the test ensures timely glucose monitoring, which is critical for the client's care.
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A client with a history of renal calculi passes a stone made up of calcium oxalate. Which of the following diet instructions should be given to the client?
- A. Increase intake of meats, eggs, fish, plums, and cranberries.
- B. Avoid citrus fruits and juices.
- C. Avoid dark green, leafy vegetables.
- D. Increase intake of dairy products.
Correct Answer: C
Rationale: Dark green, leafy vegetables are high in oxalates, which contribute to calcium oxalate stones. Meats and dairy increase other stone types, and citrus juices are beneficial.
The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial post-procedure monitoring plan should include what? Select all that apply.
- A. Level of alertness
- B. Lung sounds
- C. Oxygen saturation
- D. Respiratory pattern
- E. Temperature
- F. Urine output
Correct Answer: A,B,C,D
Rationale: Monitoring alertness, lung sounds, oxygen saturation, and respiratory pattern detects complications like pneumothorax or respiratory distress.
An anxious parent of a 4 year-old consults the nurse for guidance in how to answer the child's question, 'Where do babies come from?' What is the nurse's best response to the parent?
- A. When a child asks a question, give a simple answer.
- B. Children ask many questions, but are not looking for answers.
- C. This question indicates interest in sexual development.
- D. Full and detailed answers should be given to all questions.
Correct Answer: A
Rationale: When a child asks a question, give a simple answer. Honesty is important, but answers should be simple and age-appropriate, providing only the information the child is ready to understand.
A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4 cm by 7 cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound?
- A. Transparent dressing
- B. Dry sterile dressing with antibiotic ointment
- C. Wet to dry dressing
- D. Occlusive moist dressing
Correct Answer: D
Rationale: Occlusive moist dressing. This supports healing by maintaining a moist environment for granulation tissue.
The nurse is caring for a client with chronic venous insufficiency. Which of the following findings would be consistent with the condition?
- A. absent pedal pulses bilaterally
- B. toes cold to palpation bilaterally
- C. absence of hair on the lower extremities
- D. brown, hardened skin on the lower extremities
Correct Answer: D
Rationale: Brown, hardened skin (lipodermatosclerosis) is characteristic of chronic venous insufficiency due to hemosiderin deposition and fibrosis.