Nokea
The client's intravenous (IV) line has a gauze pad wrapped around the IV catheter at the insertion site and a transparent dressing over the gauze dressing. How long after application should the nurse change the dressing?
- A. At the normal rotation time for the IV.
- B. When the transparent dressing loosens.
- C. In 48 hours.
- D. In 24 hours.
Correct Answer: B
Rationale: Transparent dressings should be changed when they loosen (B) or per facility policy (typically every 5-7 days unless soiled or loose). Fixed intervals (C, D) or IV rotation (A) do not apply directly.
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The nurse is teaching a client on the proper technique to use an inhaler with a spacer for asthma management. Which action by the client would require intervention by the nurse?
- A. The client shakes the unit vigorously 3 or 4 times.
- B. The client places the inhaler over his tongue and seals his lips tightly around it.
- C. The client administers the next puff immediately after exhaling.
- D. The client keeps his lips closed and holds his breath for at least 10 seconds before exhaling.
Correct Answer: B
Rationale: Placing the inhaler over the tongue obstructs the airway; lips should seal around the mouthpiece with the tongue underneath. Other actions are correct.
The nurse is caring for a client with a history of schizophrenia who is experiencing auditory hallucinations. Which of the following interventions should the nurse implement?
- A. Argue with the client about the reality of the voices.
- B. Encourage the client to listen to music with earphones.
- C. Instruct the client to ignore the voices completely.
- D. Ask the client to describe the voices in detail.
Correct Answer: B
Rationale: listening to music can distract the client and reduce the intensity of auditory hallucinations
A client with cervical cancer has a radioactive implant. Which statement indicates that the client understands the nurse's teaching regarding radioactive implants?
- A. I won't be able to have visitors while getting radiation therapy.
- B. I will have a urinary catheter while the implant is in place.
- C. I can be up to the bedside commode while the implant is in place.
- D. I won't have any side effects from this type of therapy.
Correct Answer: C
Rationale: Clients with radioactive implants can use the bedside commode if the implant remains secure, indicating understanding of mobility restrictions to minimize radiation exposure.
Which of the following would be considered a sensible type of fluid loss?
- A. sweat
- B. respiratory excretions
- C. vomit
- D. water loss in feces
Correct Answer: A
Rationale: Sensible fluid loss is measurable, such as sweat or urine. Respiratory excretions, vomit, and fecal water loss are insensible (not easily measured).
The doctor has ordered a patient-controlled analgesia (PCA) pump for the client with chronic pain. The client asks the nurse if he can become overdosed with pain medication using this machine. The nurse demonstrates understanding of the PCA if she states:
- A. The machine will administer only the amount that you need to control your pain without any action from you.'
- B. The machine has a locking device that prevents overdosing.'
- C. The machine will administer one large dose every 4 hours to relieve your pain.'
- D. The machine is set to deliver medication only if you need it.'
Correct Answer: B
Rationale: The PCA pump has a lockout mechanism to prevent overdosing, ensuring safe, patient-controlled dosing.