Nokea
The nurse and unlicensed assistive personnel (UAP) are caring for a client who is experiencing an acute episode of Ménière disease. Which action by the UAP would require the nurse to intervene?
- A. Assists the client to use the bedside commode
- B. Dims the lights in the client's room
- C. Places the bed in the lowest position with all side rails raised
- D. Turns off the television in the client's room
Correct Answer: C
Rationale: Raising all side rails during an acute Ménière's episode (vertigo, nausea) increases fall risk if the client attempts to climb over them. Other actions (assisting to commode, dimming lights, turning off TV) reduce stimulation and promote safety.
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The nurse has delegated care of a client who is very hard of hearing to an unlicensed person. Which of the following would be the least helpful information to give to the unlicensed person to better facilitate communications with the client?
- A. Reduce background noise.
- B. Adjust the hearing aid.
- C. Anticipate what the client may say and finish the statement for the client.
- D. Face the client when speaking to the client.
Correct Answer: C
Rationale: Anticipating and finishing statements risks miscommunication and frustration, least helpful for effective communication with a hearing-impaired client.
A nurse is caring for a client who had a vaginal birth 2 hours ago. The nurse notes that the client's perineal pad is saturated with blood 20 minutes after placing a new pad. The client's fundus is boggy, palpable above the level of the umbilicus, and deviated to the right. Which intervention should the nurse perform first?
- A. Administer 10 units oxytocin IM
- B. Apply oxygen via nonrebreather facemask at 10 L/min
- C. Assist the client to void on a bedpan
- D. Obtain blood for a hemoglobin and hematocrit level
Correct Answer: C
Rationale: A boggy, deviated fundus and heavy bleeding suggest uterine atony and possible bladder distension preventing uterine contraction. Assisting to void relieves bladder pressure, promoting uterine involution. Oxytocin follows if bleeding persists.
The home care nurse is observing the client's spouse performing a colostomy irrigation. Which action needs correction?
- A. The spouse holds the irrigating solution about 18 inches above the stoma.
- B. The client is sitting on the toilet seat for the irrigation.
- C. The spouse is using 1000 mL of irrigating solution.
- D. The spouse uses petroleum jelly to lubricate the tip of the catheter.
Correct Answer: D
Rationale: Petroleum jelly is not suitable for lubricating colostomy irrigation catheters, as it may degrade materials or harbor bacteria; water-soluble lubricant is preferred. The height, volume, and position are appropriate.
A client with tuberculosis has an order for Rifadin (rifampin). What vitamin is usually given with rifampin?
- A. Thiamine
- B. Pyridoxine
- C. Folic acid
- D. Cyanocobalamin
Correct Answer: B
Rationale: Pyridoxine (vitamin B6) is given with rifampin to prevent peripheral neuropathy, a side effect. Other vitamins are not typically associated with rifampin therapy.
The nurse is reviewing discharge instructions with a client going home on linezolid therapy for a vancomycin-resistant enterococcus infection. Which client statement requires further teaching?
- A. I can restart my paroxetine once I get back home.
- B. I can take acetaminophen for headaches.
- C. I will avoid foods and drinks that contain tyramine.
- D. I will report any increased fever or diarrhea.
Correct Answer: A
Rationale: Linezolid interacts with SSRIs like paroxetine, risking serotonin syndrome, requiring a washout period. Acetaminophen is safe, tyramine avoidance prevents hypertensive crises, and reporting fever/diarrhea monitors treatment response.