Nokea
The client with a hearing aid does not seem to be able to hear the nurse. The nurse should do which of the following?
- A. Contact the client's audiologist.
- B. Cleanse the hearing aid ear mold in normal saline.
- C. Irrigate the ear canal.
- D. Check the hearing aid's placement.
Correct Answer: D
Rationale: Checking the hearing aid's placement is the first step, as improper placement or a low battery is a common cause of ineffective hearing aid function.
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The nurse discovers that a client's TPN solution was running at an incorrect rate and is now 2 hours behind schedule. Which action is appropriate for the nurse to take to correct the problem?
- A. Readjust the solution to infuse the desired amount.
- B. Continue the infusion at the current rate, but run the next bottle at an increased rate.
- C. Double the infusion rate for 2 hours.
- D. Notify the physician.
Correct Answer: D
Rationale: Notifying the physician is appropriate when a TPN infusion is behind schedule, as adjusting rates without an order can cause complications like hyperglycemia or circulatory overload. Continuing at the current rate or doubling the rate is unsafe. CN: Pharmacological and parenteral therapies; CL: Synthesize
The client's wife asks the nurse whether the I.V. infusion is meeting her husband's nutritional needs because he has vomited several times. The nurse's response should be based on the knowledge that 1 L of 5% dextrose in normal saline solution delivers:
- A. 170 calories.
- B. 250 calories.
- C. 340 calories.
- D. 500 calories.
Correct Answer: A
Rationale: One liter of 5% dextrose provides 50 g of dextrose, yielding approximately 170 calories, insufficient for full nutritional needs.
College freshman are participating in a study abroad program. When teaching them about hepatitis B, the nurse should instruct the students on:
- A. Water sanitation.
- B. Single dormitory rooms.
- C. Vaccine for hepatitis B.
- D. Safe sexual practices.
Correct Answer: D
Rationale: Hepatitis B is transmitted through blood and body fluids, so safe sexual practices (D) are critical for prevention. Water sanitation (A) is relevant for hepatitis A, single rooms (B) are unnecessary, and while vaccination (C) is important, the question focuses on behavioral instruction.
The wife of a terminally ill client asks the nurse, 'Why is my husband having frequent bowel movements if he is not eating?' Which of the following responses by the nurse informs the wife about the client's condition?
- A. I know he is having frequent loose stools and it is distressing for you, but that's just the way it is.
- B. I don't know when the bowels will shut down, but they will eventually.
- C. The pain medication will eventually help to slow the process of bowel function.
- D. The intestines still produce some waste products even when a person is not eating.
Correct Answer: D
Rationale: The intestines continue to produce waste from residual secretions and cellular turnover, even with minimal intake, explaining the frequent bowel movements.
A client has had a nasogastric tube connected to low intermittent suction. The client is at risk for which of the following complications?
- A. Confusion.
- B. Muscle cramping.
- C. Edema.
- D. Tremors.
Correct Answer: B
Rationale: Nasogastric suction can cause electrolyte imbalances, such as hypokalemia, leading to muscle cramping due to loss of potassium-rich gastric fluid.