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The nurse answers a call light on a client not assigned to the nurse. The client, who was just admitted from the emergency department, requests a cup of coffee. What is the appropriate intervention?
- A. Allow a family member to bring the client a cup of coffee from the cafeteria
- B. Ask the client to wait until the health care provider's (HCP's) prescriptions can be verified
- C. Delegate the task to the unlicensed assistive personnel (UAP) assigned to the client
- D. Suggest water instead until admission assessment can be completed
Correct Answer: D
Rationale: Suggesting water (D) is safe until dietary orders are confirmed. Coffee (A, C) may be contraindicated, and waiting (B) doesn't address the request.
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The clinic nurse is planning to assess the visual acuity of a 6-year-old. Which method is the best way to assess visual acuity in this child?
- A. Have the child identify different objects using Allen figure testing cards
- B. Have the child point in the direction each letter is facing on a tumbling E chart
- C. Have the child read letters on a Snellen chart while standing 10 ft (3 m) away
- D. Have the child view a set of Ishihara colored cards one at a time
Correct Answer: B
Rationale: The tumbling E chart (B) is age-appropriate for a 6-year-old, who may not know letters. Allen cards (A) are for younger children, Snellen at 10 ft (C) is non-standard, and Ishihara (D) tests color vision.
The nurse is reinforcing discharge instructions for several clients. Which client should receive information about the need for prophylactic antibiotics prior to dental procedures?
- A. Client who had mechanical aortic valve replacement
- B. Client who had mitral valvuloplasty repair
- C. Client who had myocardial infarction with subsequent heart failure
- D. Client who has mitral valve prolapse with regurgitation
Correct Answer: A
Rationale: Mechanical valve replacements (A) require prophylactic antibiotics before dental procedures to prevent endocarditis. Mitral valvuloplasty (B), heart failure (C), and mitral valve prolapse with regurgitation (D) have lower risks.
A nurse is collecting data on a 58-year-old client with blurred vision and reduced visual fields. The nurse finds which manifestation most concerning?
- A. Difficulty adjusting to dimmed lights
- B. Extreme eye pain
- C. Gradual loss of peripheral vision
- D. Opaque appearance of lens
Correct Answer: B
Rationale: Extreme eye pain (B) suggests acute conditions like glaucoma, requiring urgent attention. Difficulty in dim light (A), peripheral vision loss (C), and cataracts (D) are less acute.
The nurse is assessing a client at 11 weeks gestation. The first day of the client's last menstrual period was September 7. Which of the following findings should the nurse expect to obtain?
- A. reports feeling fetal movement
- B. reports increased urinary frequency
- C. fundal height of 24 cm above the symphysis pubis
- D. estimated delivery date of June 14 using the Naegele rule
- E. fetal heart tones detectable via Doppler ultrasound device
Correct Answer: B,D,E
Rationale: At 11 weeks, increased urinary frequency (B) is expected due to hormonal changes. The Naegele rule (LMP + 1 year - 3 months + 7 days) gives June 14 (D). Fetal heart tones are detectable by Doppler (E). Fetal movement (A) is felt later (16-20 weeks), and fundal height of 24 cm (C) occurs around 24 weeks.
Prior to administering a feeding, the nurse checks for placement of a feeding tube. What is the best way to do this?
- A. Check for residual
- B. Measure the pH of aspirated gastrointestinal fluid
- C. Inject 10 to 20 mL of air while auscultating over the epigastric area
- D. Ask the client to talk or hum
Correct Answer: B
Rationale: Measuring the pH of aspirated fluid (pH <5.5) confirms gastric placement, the most reliable method to prevent aspiration.