Nokea
The newly licensed nurse has been asked to perform a procedure that he feels unqualified to perform. The nurse's best response at this time is to:
- A. Attempt to perform the procedure
- B. Refuse to perform the procedure and give a reason for the refusal
- C. Request to observe a similar procedure and then attempt to complete the procedure
- D. Agree to perform the procedure if the client is willing
Correct Answer: B
Rationale: Refusing and explaining the lack of qualification ensures patient safety and adheres to ethical standards.
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The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
- A. Use the heel of her hand during percussion
- B. Change the child's position every 20 minutes during percussion sessions
- C. Do percussion after the child eats and at bedtime
- D. Use cupped hands during percussion
Correct Answer: D
Rationale: Cupped hands during chest percussion create a vibration that helps loosen mucus in cystic fibrosis without causing injury.
The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
- A. I will make sure I eat breakfast within 2 hours of taking my insulin.
- B. I will need to carry candy or some form of sugar with me all the time.
- C. I will eat a snack around three o'clock each afternoon.
- D. I can save my dessert from supper for a bedtime snack.
Correct Answer: C
Rationale: NPH insulin peaks 4-12 hours after administration, so a snack around 3 PM helps prevent hypoglycemia during peak action.
The nurse is assessing a client hospitalized with duodenal ulcer. Which finding should be reported to the doctor immediately?
- A. BP 82/60, pulse 120
- B. Pulse 68, respirations 24
- C. BP 110/88, pulse 56
- D. Pulse 82, respirations 16
Correct Answer: A
Rationale: A blood pressure of 82/60 and pulse of 120 indicate possible hypovolemic shock, likely due to gastrointestinal bleeding, which is a medical emergency requiring immediate reporting.
The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client's diet?
- A. Roasted chicken
- B. Noodles
- C. Cooked broccoli
- D. Custard
Correct Answer: C
Rationale: Cooked broccoli is high in fiber and should be avoided on a low-roughage diet for diverticulitis to prevent irritation.
The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:
- A. Assess the urinary output
- B. Obtain arterial blood gases
- C. Perform a dextrostick
- D. Obtain a stool culture
Correct Answer: A
Rationale: Adequate urinary output (at least 30 mL/hr) must be confirmed before adding potassium to IV fluids to prevent hyperkalemia.