Nokea
The home nurse who is caring for an older person who has chronic obstructive pulmonary disease (COPD) with continuous nasal oxygen is helping the family set up a humidifier in the room. The humidifier cord is not long enough to reach the outlet in the room and must be plugged into an extension cord. The extension cord is wrapped with black tape. When the nurse asks the family members about the tape, they reply that the cord is an old cord, and the electrical tape covers up the frayed part and makes it safe. They say a contractor friend told them how to make it safe. How should the nurse respond?
- A. Refuse to set up the equipment until a new cord is available
- B. Carefully inspect the taped area and set up equipment if it appears intact
- C. Ask the family to let the nurse discuss the safety of the cord with the contractor friend
- D. Set up the equipment and suggest that the family get a new extension cord as soon as possible
Correct Answer: A
Rationale: A frayed cord poses a fire hazard, especially with oxygen use. Refusing to set up until a safe cord is available prioritizes safety.
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The nurse observes that a child with muscular dystrophy has a positive Gower's sign. The nurse documents that the child:
- A. Has weak deep tendon reflexes
- B. Must use his hands to rise from the floor
- C. Has increased spinal reflexes
- D. Rocks back and forth in rhythmical fashion
Correct Answer: B
Rationale: A positive Gower's sign indicates the child uses their hands to push up from the floor due to muscle weakness, so B is correct. Answers A, C, and D do not describe Gower's sign.
A Jewish client requires grafting to promote burn healing. Which graft is most likely to be unacceptable to the client?
- A. Isograft
- B. Autograft
- C. Homograft
- D. Xenograft
Correct Answer: D
Rationale: A Jewish client may find a xenograft unacceptable due to religious dietary laws that prohibit the use of certain animal products, such as porcine grafts. An isograft (from an identical twin), autograft (from the client's own body), and homograft (from a human donor) are generally more acceptable. Answers A, B, and C are incorrect because they do not typically conflict with Jewish religious beliefs.
The nurse is caring for a man who has chronic emphysema and is receiving oxygen at 2 L/min. The nurse enters the room to find that his wife has turned the oxygen up to 10 L/min because her husband is having increasing difficulty breathing. What is the best immediate action for the nurse to take?
- A. Explain to the wife that his oxygen was ordered at 2 L/min and it should stay there until the physician orders something else
- B. Turn the oxygen setting back to 2 L/min
- C. Tell the wife that 10 L/min is too high and turn it back to 5 L/min
- D. Assure her that 10 L/min will ease her husband's breathing
Correct Answer: B
Rationale: High oxygen in emphysema can suppress respiratory drive, worsening hypercapnia; returning to 2 L/min is critical, followed by physician consultation.
A 32-year-old multipara is seen in the prenatal clinic. The nurse notes she is in her fifth month of pregnancy and has a weight gain of 14 pounds. The history indicates that prenatally the client was of average height and weight.
The nurse should advise the client that
- A. she has gained too much weight and her diet should be reevaluated.
- B. she has not gained enough weight and her diet should be reevaluated.
- C. her weight gain is appropriate and she should continue on her present diet.
- D. her weight gain indicates that she may have difficulties later in pregnancy.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) excessive weight gain is >6.6 lb (3 kg)/month (2) inadequate weight gain is <2.2 lb (1 kg)/month (3) correct-weight gain 2-5 lb (2.5 kg) first trimester, 0.66-1.1 lb (0.5 kg) weekly in second and third trimester (4) not substantiated by information presented in question
The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the discharge list in order to make room for a new admission?
- A. A middle aged client with a 7 year history of being ventilator dependent and who was admitted with bacterial pneumonia five days ago
- B. A young adult with Type 2 diabetes mellitus for over 10 years and who was admitted with antibiotic-induced diarrhea 24 hours ago
- C. An elderly client with a history of hypertension, hypercholesterolemia and lupus, and who was admitted with Stevens-Johnson syndrome that morning
- D. An adolescent with a positive HIV test and who was admitted for acute cellulitis of the lower leg 48 hours ago
Correct Answer: A
Rationale: The best candidate for discharge is one who has a chronic condition and has an established plan of care. The client in option A is most likely stable and could continue medication therapy at home.