Nokea
The nurse enters the client's room and smells cigarette smoke. When confronted, the client says, 'I only smoked one cigarette because I was having a bad craving.' Which action by the nurse is most appropriate?
- A. escort the client outside to smoke
- B. call the health care provider to obtain an order for a nicotine patch
- C. remind the client that oxygen is in use and smoking is banned in the facility
- D. tell the client that if he continues to smoke in the room, he will be discharged from the hospital
Correct Answer: C
Rationale: Reminding the client of the danger of smoking near oxygen and hospital policy addresses safety and compliance immediately.
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The client with a myocardial infarction comes to the nurse's station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using?
- A. Rationalization
- B. Denial
- C. Projection
- D. Conversion reaction
Correct Answer: B
Rationale: Denial involves refusing to acknowledge a serious condition.
An elderly client's wife tells a nurse she is concerned because her husband insists on talking about past events. The nurse assesses the client and finds him alert, oriented, and responsive to questions. Which statement should the nurse make to the client's wife?
- A. Your husband is choosing to live in a happier time in his life.
- B. Redirect your husband to speak about current events when he begins regressing into the past.
- C. If he were my husband, I would call our minister to speak to him.
- D. Your husband is reflecting on his life. This is normal at his age.
Correct Answer: D
Rationale: Reflecting on past events is a normal part of aging, especially in older adults, and this response reassures the wife while providing accurate information.
After the physician performs an amniotomy, the nurse's first action should be to assess the:
- A. Degree of cervical dilation
- B. Fetal heart tones
- C. Client's vital signs
- D. Client's level of discomfort
Correct Answer: B
Rationale: Post-amniotomy, assessing fetal heart tones is critical to detect potential cord prolapse or distress.
The nurse is administering terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client’s pulse to be 144. The nurse’s priority action should be to
- A. withhold the medication.
- B. decrease the dose by half.
- C. administer the medication.
- D. wait 15 minutes, then recheck the rate.
Correct Answer: A
Rationale: maternal tachycardia is a side effect of Brethine; other maternal side effects include nervousness, tremors, headache, and possible pulmonary edema; fetal side effects include tachycardia and hypoglycemia; Brethine is usually preferred over ritodrine (Yutopar) because it has minimal effects on blood pressure
A 19-year-old female is admitted to the psychiatric floor after a suicide attempt 3 days ago. With client safety a priority, the nurse should
- A. assign the patient to the room closest to the nursing station.
- B. assign the patient to an open room with a roommate.
- C. assign the patient to a secluded, isolated room.
- D. assign a staff member to stay with the client at all times.
Correct Answer: A
Rationale: Placing the client near the nursing station allows close monitoring without isolation, balancing safety and autonomy. Constant staff presence is resource-intensive and not always necessary.