Nokea
A two-year-old who is one-day postoperative.
The mother of a two-year-old who is one-day postoperative tells the nurse, 'My child is so restless and overactive.' The nurse should
- A. direct the LPN/LVN to obtain the child's vital signs.
- B. ask the mother if the child's sutures are still intact.
- C. tell the nursing assistant to take the child for a walk.
- D. check to see when the child last received pain medication.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? Yes. Determine the best assessment. (1) no indication that there are any problems (2) passing the buck (3) implementation, should first assess (4) correct-young children typically become restless and overactive if in pain, grimacing, clenching teeth, rocking, and aggressive behavior may also be observed
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The nurse is teaching a client with hypertension about dietary modifications. Which of the following foods should the nurse recommend the client avoid?
- A. Baked chicken breast.
- B. Canned vegetable soup.
- C. Fresh apples.
- D. Whole-grain bread.
Correct Answer: B
Rationale: Canned vegetable soup is high in sodium, which can exacerbate hypertension. Options A, C, and D are suitable: baked chicken is low-sodium, apples are heart-healthy, and whole-grain bread supports cardiovascular health.
The nurse is caring for a client with Ménière's disease. The nurse stands directly in front of the client when speaking. Which of the following BEST describes the rationale for the nurse's position?
- A. This enables the client to read the nurse's lips.
- B. The client does not have to turn her head to see the nurse.
- C. The nurse will have the client's undivided attention.
- D. There is a decrease in client's peripheral visual field.
Correct Answer: B
Rationale: by decreasing movement of client's head, vertigo attacks may be decreased
A client who is terminally ill has been receiving high doses of an opioid analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli, what orders would the nurse expect from the health care provider?
- A. Decrease the analgesic dosage by half
- B. Discontinue the analgesic
- C. Continue the same analgesic dosage
- D. Prescribe a less potent drug
Correct Answer: C
Rationale: Continue the same analgesic dosage. Dying patients who have been in chronic pain will probably continue to experience pain even though they cannot communicate their experience. Pain medication should be continued at the same dose, if effective.
A client has been transferred from a nursing home to the hospital with an indwelling urinary catheter. The urine is cloudy and foul-smelling.
Which of the following nursing measures would be MOST appropriate?
- A. Clean the urinary meatus every other day.
- B. Encourage the client to increase fluid intake.
- C. Empty the drainage bag every 2-4 hours.
- D. Irrigate the Foley catheter every 8 hours.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the problem of the client's urine, should not be performed (2) correct-increasing intake of fluids is an appropriate independent nursing action that facilitates removal of concentrated urine (3) does not address the problem of the client's urine, should not be performed (4) could increase the chance of developing an infection
A 52-year-old woman complains of chronic constipation.
The nurse in the health care clinic should advise the woman to
- A. reduce her intake of highly seasoned foods and fats.
- B. drink 1,000 cc of fluids daily.
- C. increase her intake of cereals, fresh fruits, and vegetables.
- D. ask her physician to prescribe Dulcolax 5 mg enteric-coated tablets daily.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unnecessary, no effect on constipation (2) normal intake 1,500-2,000, reduced intake causes constipation (3) correct-bulk-forming foods help with constipation (4) passing the buck, laxatives are a last resort