Nokea
The nurse in the long-term care facility discovers a client with dementia wandering in the hallway during the night. Which of the following statements would be most appropriate for the nurse to make?
- A. What are you doing in the hallway? It is not time to wake up yet
- B. You should stop walking in the hallway at night because you might fall
- C. You are in the long-term care facility. Let us go back to your room together
- D. Ask a staff member to accompany you the next time you wish to leave your room
Correct Answer: C
Rationale: Orienting the client and gently redirecting them to their room is calming and safe. Questioning, warning, or instructing may confuse or agitate a client with dementia.
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An adult is receiving cancer chemotherapy. Metoclopramide (Reglan) is also prescribed. The client asks why she is getting Reglan. How should the nurse respond?
- A. Reglan helps to prevent bleeding that may occur as a side effect of your other medications.'
- B. Reglan helps to prevent any nausea and vomiting that may occur as a side effect of your other medications.'
- C. Reglan increases the effectiveness of the cancer chemotherapeutic agents.'
- D. Reglan helps to control pain associated with your disease.'
Correct Answer: B
Rationale: Metoclopramide is an antiemetic, prescribed to prevent nausea and vomiting, common chemotherapy side effects, improving patient comfort.
The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, 'I will receive tissue from
- A. a tissue bank.
- B. a pig.
- C. my thigh.
- D. synthetic skin.
Correct Answer: C
Rationale: Autografts are done with tissue transplanted from the client's own skin.
The nurse is reinforcing teaching regarding home oxygen use for a client with emphysema who is using nasal cannula and portable oxygen tank. Which of the following statements by the client would require follow-up? Select all that apply.
- A. I can continue to cook on my gas stove.
- B. I can use a humidifier if my nostrils feel dry.
- C. I need to keep a working fire extinguisher in my home.
- D. I should use a wool blanket on my bed instead of cotton.
- E. I can increase the oxygen flow rate whenever I feel short of breath.
Correct Answer: A,D,E
Rationale: Oxygen therapy is commonly prescribed to improve oxygenation for clients with (or at risk for) hypoxia (eg, emphysema) and to promote comfort in clients receiving palliative/hospice care. Clients requiring long-term oxygen therapy may be prescribed portable oxygen delivery (ie, home oxygen therapy) to allow increased independence in daily life.
A 4-month-old infant is being treated for talipes equinovarus (clubfoot). The nurse should include which of the following in the priority teaching plan for the parents?
- A. Monitor respiratory rate
- B. Monitor intake and output every hour
- C. Assist the client to breathe into a paper bag
- D. Prepare to administer oxygen by mask
Correct Answer: C
Rationale: Assisting the client to breathe into a paper bag addresses hyperventilation caused by aspirin toxicity, which can lead to respiratory alkalosis in the initial stages.
The nurse in the outpatient clinic is caring for assigned clients with type 1 diabetes mellitus. Which client should the nurse recognize as having the highest risk of developing hypoglycemia?
- A. 29-year-old client with new-onset influenza
- B. 40-year-old client who is a cyclist and is training for an upcoming race
- C. 65-year-old client with cellulitis of the right leg
- D. 72-year-old client with emphysema who is receiving prednisone
Correct Answer: D
Rationale: Prednisone increases blood glucose, but abrupt cessation or dose changes can cause hypoglycemia in type 1 diabetes due to insulin sensitivity. Influenza, exercise, and cellulitis pose risks, but prednisone’s metabolic impact is greatest.