Nokea
The client admitted with rule-out Guillain-Barré syndrome has just had a lumbar puncture. Which intervention should the nurse implement postprocedure?
- A. Monitor the client for hypotension.
- B. Apply pressure to the puncture site.
- C. Test the client's cerebrospinal fluid.
- D. Increase the client's fluid intake.
Correct Answer: D
Rationale: Increasing fluid intake post-lumbar puncture prevents spinal headache. Hypotension is not a primary concern, pressure is applied during the procedure, and CSF testing is lab-based.
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The charge nurse observes the primary nurse interacting with a client. Which action by the primary nurse warrants immediate intervention by the charge nurse?
- A. The nurse explains the IVP diuretic will make the client urinate.
- B. The nurse dons nonsterile gloves to remove the client's dressing.
- C. The nurse administers a medication without checking for allergies.
- D. The nurse asks the UAP for help moving a client up in bed.
Correct Answer: C
Rationale: Administering medication without checking allergies risks allergic reactions, requiring immediate intervention. Diuretic explanation, glove use, and UAP assistance are appropriate.
The client diagnosed with myasthenia gravis is admitted with an acute exacerbation. Which interventions should the nurse implement? Select all that apply.
- A. Assist the client to turn and cough every two (2) hours.
- B. Place the client in a high or semi-Fowler's position.
- C. Assess the client's pulse oximeter reading every shift.
- D. Plan meals to promote medication effectiveness.
- E. Monitor the client's serum anticholinesterase levels.
Correct Answer: A,B,C,D
Rationale: Turning/coughing, Fowler’s position, pulse oximetry, and meal timing address respiratory risk and medication efficacy in myasthenia gravis. Serum anticholinesterase levels are not routinely monitored.
The client in the HCP's office is complaining of allergic rhinitis. Which assessment question is important for the nurse to ask the client?
- A. What time of year do the symptoms occur?
- B. Which over-the-counter medications have you tried?
- C. Do other members of your family have allergies to animals?
- D. Why do you think you have allergies?
Correct Answer: A
Rationale: Seasonal patterns help identify allergic rhinitis triggers. Medications, family history, and client beliefs are secondary.
Which collaborative health-care team member should the nurse refer the client to in the late stages of myasthenia gravis?
- A. Occupational therapist.
- B. Recreational therapist.
- C. Vocational therapist.
- D. Speech therapist.
Correct Answer: D
Rationale: Speech therapists address dysphagia and communication issues in late-stage myasthenia gravis. Other therapists are less relevant.
Which nursing intervention should the nurse include when teaching the client diagnosed with polymyositis?
- A. Explain the care of a percutaneous endoscopic gastrostomy tube.
- B. Discuss the need to take corticosteroids every day.
- C. Instruct to wear long-sleeved shirts when exposed to sunlight.
- D. Teach the importance of strict hand washing.
Correct Answer: B
Rationale: Corticosteroids are mainstay treatment for polymyositis, reducing muscle inflammation. PEG tubes, sun protection, and handwashing are less relevant.