Nokea
The following clients are to be assigned for daily care. The newly licensed nurse should not be assigned to provide primary care for the client with:
- A. Full-thickness burns of the abdomen and upper thighs
- B. A fractured hip scheduled for hip replacement
- C. Ileal reservoir following a cystectomy
- D. Noncardiogenic pulmonary edema (ARDS)
Correct Answer: D
Rationale: ARDS requires complex respiratory management, which is beyond the scope of a newly licensed nurse.
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The nurse is developing a plan for bowel and bladder retraining for a client with paraplegia. The primary goal of a bowel and bladder retraining program is:
- A. Optimal restoration of the client's elimination pattern
- B. Restoration of the client's neurosensory function
- C. Prevention of complications from impaired elimination
- D. Promotion of a positive body image
Correct Answer: C
Rationale: The primary goal is to prevent complications like infections or skin breakdown by establishing effective bowel and bladder management.
A client is admitted with suspected Legionnaires' disease. Which factor increases the risk of developing Legionnaires' disease?
- A. Treatment of arthritis with steroids
- B. Foreign travel
- C. Eating fresh shellfish twice a week
- D. Doing volunteer work at the local hospital
Correct Answer: A
Rationale: Steroid use increases the risk of Legionnaires' disease by suppressing the immune system, making individuals more susceptible to Legionella infection.
The client with a pacemaker should be taught to:
- A. Report ankle edema
- B. Check his blood pressure daily
- C. Refrain from using a microwave oven
- D. Monitor his pulse rate
Correct Answer: D
Rationale: Monitoring pulse rate ensures the pacemaker is functioning correctly and detects arrhythmias.
The nurse is part of an interdisciplinary team in a rehabilitation unit. Which of the following statements by a client is most important to be communicated to the social worker on the team?
- A. I can't afford to hire anyone to help me when I am discharged.
- B. I'm worried about falling when I go home.
- C. I need to learn how to get in and out of the shower.
- D. I'm not sure what kinds of adaptive equipment I will need.
Correct Answer: A
Rationale: Inability to afford help (A) is a social issue requiring the social worker's intervention for resources. Other concerns (B, C, D) are addressed by therapy or nursing.
The nurse arrives at a motorcycle accident and finds the client unresponsive, apneic, and pulseless. After calling for a spectator to help, what would be the nurse's next action?
- A. Ventilate with a mouth-to-mask device
- B. Begin chest compressions
- C. Administer a precordial thump
- D. Open the airway
Correct Answer: B
Rationale: Per ACLS guidelines, for an unresponsive, apneic, pulseless client, start chest compressions immediately after calling for help to restore circulation.