Nokea
The client has just returned from having a cast placed on the right forearm and is found putting a lead pencil in the cast to 'reach the itch.' What is the nurse's priority action?
- A. Offer the client a straw to reach the itch instead of a lead pencil
- B. Perform a peripheral neurovascular check of the casted extremity
- C. Pour a generous amount of baby powder or corn starch in the cast to reach the itch
- D. Review appropriate itch relief technique using the cool setting of a hair dryer
Correct Answer: D
Rationale: Using a hair dryer on a cool setting is a safe and effective way to relieve itching without risking skin damage or cast integrity, unlike inserting objects or powders.
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An adult who has hepatitis A asks the nurse why her skin is yellow. The nurse should include which information when replying?
- A. The diseased liver is not able to convert bilirubin into bile, so bilirubin pigments stay in the bloodstream and cause the skin and sclera to turn yellow.
- B. The virus that causes hepatitis A leaves a yellow pigment in the bloodstream.
- C. The affected liver cells produce more bilirubin than usual, causing the skin to turn yellow.
- D. The body is trying to get rid of fecal waste products through the skin.
Correct Answer: A
Rationale: Hepatitis A impairs liver function, reducing bilirubin conjugation and excretion, leading to its accumulation in the blood, causing jaundice. The virus does not produce pigment, nor does the liver overproduce bilirubin or excrete waste through skin.
The nurse is planning care for a client who has a hearing impairment. Which action will likely help the most with communication?
- A. Repeat everything twice.
- B. Speak loudly.
- C. Speak slowly and clearly.
- D. Use gestures.
Correct Answer: C
Rationale: Speaking slowly and clearly enhances comprehension for hearing-impaired clients. Repeating, shouting, or gestures may confuse or overwhelm.
Which one of these tasks can be safely delegated to a practical nurse (PN)?
- A. Assess the function of a newly created ileostomy
- B. Care for a client with a recent complicated double barrel colostomy
- C. Provide stoma care for a client with a well functioning ostomy
- D. Teach ostomy care to a client and their family members
Correct Answer: C
Rationale: Provide stoma care for a client with a well functioning ostomy. The care of a mature stoma and the application of an ostomy appliance may be delegated to a PN. This client has minimal risk of instability of the situation.
The nurse is collecting data from a client with heart failure. The nurse notes that the client is agitated, has crackles bilaterally, and is reporting dyspnea and anxiety. The nurse should place the client in
- A. modified Trendelenburg position
- B. high Fowler position
- C. left Sims position
- D. supine position
Correct Answer: B
Rationale: High Fowler position optimizes lung expansion and reduces preload, alleviating dyspnea and crackles in acute heart failure exacerbation.
The nurse has been interacting for several weeks with a client on the psychiatric unit. The nurse is to be transferred to another unit. Which comment by the client indicates separation anxiety?
- A. We had a good time at the party last night. You should have been here.'
- B. Some of us are going to the museum next week. Too bad you can't go.'
- C. I was thinking about my friend last night; the one who died in the car crash.'
- D. I was telling my wife what a good nurse you are.'
Correct Answer: B
Rationale: Expressing regret about the nurse missing a future event suggests attachment and anxiety about the nurse's departure, indicating separation anxiety. Other comments lack this emotional connection.