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The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?
- A. Maintain the client's systolic blood pressure at 70mmHg or greater
- B. Maintain the client's urinary output greater than 300cc per hour
- C. Maintain the client's body temperature above 33°F rectal
- D. Maintain the client's hematocrit below 30%
Correct Answer: A
Rationale: When caring for a client on ventilator support pending organ donation, maintaining the systolic blood pressure at 70mmHg or greater is crucial to ensure a proper blood supply to the donor organ. This goal is a priority to maintain the viability of the organ for donation. Choices B, C, and D are incorrect because they are unnecessary and not directly related to the immediate goal of organ donation. Maintaining urinary output, body temperature, or hematocrit levels are not the primary concerns in this situation.
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The nurse provides a postoperative client with an analgesic medication and darkens the room before the client goes to sleep for the night. The nurse's actions:
- A. help decrease stimuli from the cerebral cortex.
- B. stimulate hormonal changes in the brain.
- C. help the client's circadian rhythm.
- D. alert the hypothalamus in the brain.
Correct Answer: A
Rationale: The nurse's actions of providing an analgesic medication and darkening the room aim to decrease stimuli from the cerebral cortex. Reduction of environmental stimuli, especially light and noise, from the cerebral cortex, which is an area of arousal, facilitates sleep. By decreasing input to this area, the client is more likely to fall asleep and stay asleep. Choices B, C, and D are incorrect because the scenario does not involve stimulating hormonal changes, influencing the circadian rhythm, or alerting the hypothalamus.
To assess a client's ankle ROM, which ROM exercises should the nurse have them perform?
- A. flexion, extension, hyperextension
- B. flexion, extension, abduction, adduction
- C. external rotation, internal rotation
- D. extension, flexion, inversion, eversion
Correct Answer: D
Rationale: The correct answer is extension, flexion, inversion, and eversion. These exercises help assess the full range of motion of the ankles. Flexion and extension evaluate the bending and straightening movements of the ankle joint, respectively. Inversion and eversion assess the inward and outward movements of the foot at the ankle joint. Hyperextension, abduction, and adduction are not specific movements of the ankle joint, making choices A and B incorrect. External and internal rotation are movements more related to joints like the hip or shoulder, not the ankle, making choice C incorrect.
Which of the following statements by an adult child of a client with late-stage Alzheimer's disease indicates a need for further teaching by the nurse?
- A. "I should provide a regular schedule for toileting."?
- B. "I should talk to my father less because he can't communicate."?
- C. "I should give my father oral care after every meal and bedtime."?
- D. "I should assist my father with eating and drinking."?
Correct Answer: B
Rationale: In late-stage Alzheimer's disease, although verbal communication may be challenging or limited, it is essential to maintain communication through talking and non-verbal cues like touching. Limiting communication can lead to feelings of isolation and worsen the emotional well-being of the individual. Choices A, C, and D reflect appropriate care strategies by addressing toileting needs, oral care, and assistance with eating and drinking, which are crucial aspects of caregiving for a client with late-stage Alzheimer's disease.
When managing nausea related to Morphine epidural analgesia, the nurse should administer:
- A. Indomethacin
- B. Codeine
- C. Ibuprofen
- D. Compazine
Correct Answer: D
Rationale: When managing nausea related to Morphine epidural analgesia, Compazine is the appropriate medication to administer. Compazine, also known as prochlorperazine, is commonly used to treat nausea and vomiting. It works by affecting certain chemicals in the brain that trigger nausea and vomiting. Choices A, B, and C are incorrect because Indomethacin, Codeine, and Ibuprofen are not typically used to manage nausea associated with Morphine epidural analgesia.
The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?
- A. pureed canned squash
- B. pureed apples
- C. yogurt
- D. infant rice cereal
Correct Answer: D
Rationale: The correct answer is infant rice cereal. Single-grain infant cereals are recommended as the first solid food because they are easily digestible and have added iron content. Choice C, yogurt, is incorrect because yogurt is a milk product and should be delayed until the child is 12 months old due to the risk of milk allergy. Choices A and B are incorrect because fruits and vegetables are typically introduced after cereals to help the infant get accustomed to solid foods gradually.