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Which of the following instructions should the nurse include in the teaching?
- A. Apply cold packs directly on the skin of the affected joints
- B. Administer biological response modifiers to prevent infection
- C. Take a hot shower in the morning to decrease stiffness
- D. Cluster physical activities during the day
Correct Answer: C
Rationale: The correct answer is C: Take a hot shower in the morning to decrease stiffness. This instruction is appropriate for managing symptoms of arthritis by helping to reduce stiffness in the joints. Cold packs directly on the skin (choice A) can worsen symptoms. Administering biological response modifiers (choice B) is not a nursing role. Clustering physical activities during the day (choice D) can help manage symptoms but is not as specific or targeted as a hot shower for reducing stiffness.
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Which of the following tasks should the charge nurse assign to a licensed practical nurse?
- A. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus.
- B. Complete the Glasgow Coma Scale for a client who has an evolving stroke.
- C. Perform a sterile dressing change for a client who has an abdominal wound.
- D. Perform an admission assessment for a client who is scheduled for surgery.
Correct Answer: C
Rationale: LPNs are trained for sterile dressing changes.
Which of the following findings should the nurse expect?
- A. The client is oriented times three
- B. The client opens eyes to sound.
- C. The client is unable to obey commands.
- D. The client withdraws from pain
Correct Answer: A
Rationale: The correct answer is A: The client is oriented times three. This indicates that the client is alert and aware of person, place, and time. This finding is crucial in assessing the client's mental status and cognitive function. Opening eyes to sound (B) is a basic response but does not indicate orientation. Inability to obey commands (C) suggests altered mental status. Withdrawing from pain (D) may indicate a physical reflex rather than cognitive function. Overall, being oriented times three is the most comprehensive assessment of mental alertness and cognitive function.
Which of the following actions should the nurse plan to take?
- A. The nurse should use a filter needle to withdraw the medication.
- B. The nurse should break the neck of the ampule toward their body
- C. The nurse should use the same needle to draw up and inject the client
- D. The nurse should dispose of the ampule in the trash can.
Correct Answer: A
Rationale: The correct answer is A: The nurse should use a filter needle to withdraw the medication. This is the correct action as filter needles help prevent the introduction of particulate matter or impurities into the medication, ensuring patient safety. Using a filter needle also reduces the risk of needlestick injuries and contamination.
Choice B is incorrect as breaking the neck of the ampule towards the body increases the risk of injury due to glass shards flying towards the nurse. Choice C is incorrect as it violates safe medication administration practices by risking contamination. Choice D is incorrect as ampules should be disposed of in a sharps container, not the trash can.
A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?
- A. Soak feet twice daily.
- B. Round the edges of toenails when trimming
- C. Use moisturizing lotion between the toes.
- D. Wear clean cotton socks every day.
Correct Answer: D
Rationale: The correct answer is D: Wear clean cotton socks every day. This instruction is crucial for diabetic foot care as it helps prevent moisture buildup, reduces the risk of infections, and maintains proper foot hygiene. Clean cotton socks minimize friction, provide cushioning, and promote good circulation.
Rationale for other choices:
A: Soaking feet twice daily can lead to dry skin, increasing the risk of skin breakdown and infection.
B: Rounding the edges of toenails can cause injury and increase the risk of ingrown toenails.
C: Using moisturizing lotion between the toes can create a moist environment, promoting fungal growth and skin maceration.
Which of the following questions is the priority for the nurse to ask the client?
- A. How do you manage your behavior?
- B. Do you have a criminal record?
- C. How do you get along with your peers at school?
- D. Do you have thoughts of harming yourself?
Correct Answer: D
Rationale: The correct answer is D. The nurse's priority is to assess for any immediate danger or harm to the client. Asking about thoughts of harming oneself is crucial in determining the client's safety. This question helps identify the client's risk of suicide and allows for timely intervention if needed. Choices A, B, and C focus on different aspects of the client's behavior and relationships, which are important but not as urgent as assessing for suicidal ideation. It is essential to address safety concerns first before exploring other areas.