Nokea
The nurse in the outpatient clinic teaches the mother of a 10-year-old boy with asthma how to prevent future asthmatic attacks.
- A. Which statement by the mother indicates the nurse should be most concerned?
- B. My son plays the tuba in the grade school band.'
- C. My son loves to help his dad rake leaves.'
- D. My son participates in after-school activities three days a week.'
- E. My son walks one mile to school every day with his friends.'
Correct Answer: B
Rationale: Raking leaves exposes the child to inhaled allergens like pollen and dust, which are primary asthma triggers. Playing the tuba, participating in activities, and walking are unlikely to trigger asthma unless exercise-induced, which is not indicated.
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The nurse enters an adult's room to premedicate for surgery. The client says, 'You know, nurse, that form I signed said something about a nephrectomy. What does that mean?' How should the nurse respond initially?
- A. What did your surgeon explain to you about your operation?'
- B. Don't worry about the technical terms. We'll take good care of you.'
- C. I think you're just nervous about the surgery. This injection will make you feel calmer.'
- D. It is a kidney operation.'
Correct Answer: A
Rationale: Asking what the surgeon explained clarifies the client's understanding, ensuring informed consent and addressing concerns.
Which comment is the client who has Parkinson's disease most likely to make?
- A. My hands shake when I reach to pick up my coffee cup.'
- B. I get very stiff when I sit for long periods of time.'
- C. I have to drink a lot because my mouth is so dry.'
- D. It is easier for me to pick up my feet than to slide them.'
Correct Answer: B
Rationale: Rigidity and stiffness, especially after immobility, are hallmark Parkinson's symptoms, unlike tremors (more action-specific), dry mouth, or gait preferences.
The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client?
- A. Ask the client and family if they are satisfied with the care given
- B. Determine the home health aide is care to a consistent with the plan of care
- C. Investigate if the home health aide is prompt and stays an appropriate length of time for care
- D. Check the documentation of the aide for appropriateness and comprehensiveness
Correct Answer: B
Rationale: Although the nurse must complete all of the above responsibilities, evaluation of an adherence to the plan of care is the first priority. The plan of care is based on the reason for referral, provider's orders, the initial nursing assessment, the client's responses to the planned interventions, and the client's and family's feedback or inquiries.
A four-year-old child with sickle cell anemia.
The nurse is aware that which of the following statements, if made by the parents of a four-year-old child with sickle cell anemia, indicates a need for further teaching?
- A. When my daughter complains of pain, I give her baby aspirin.'
- B. I try to keep my daughter away from people with infections.'
- C. I sometimes have to give my daughter some of her Demerol for pain.'
- D. I encourage my daughter to drink a lot of water.'
Correct Answer: A
Rationale: Strategy: 'Need for further teaching' indicates you are looking for an incorrect behavior. (1) correct-aspirin can cause a hemorrhage during a sickle cell crisis (2) important for a sickle cell client to prevent sickling crisis (3) reflects appropriate use of medication to decrease the client's pain (4) important for a sickle cell client to prevent sickling crisis
An adult client with a nasogastric tube has an order for acetaminophen (Tylenol) 650 mg PRN for a temperature greater than 101°F (38.3°C).
Which of the following measures should be included by the nurse when administering this medication?
- A. The tablets should be swallowed carefully with sips of water.
- B. The medication should be withheld until the nasogastric tube is removed.
- C. Placement of the nasogastric tube should be checked prior to giving the medication.
- D. Powdered medication should be used and mixed with water to form a solution.
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is NPO, so nothing should be administered orally (2) medication should not be withheld (3) correct-liquid acetaminophen may be administered via the nasogastric tube after tube placement has been checked; tube placement should be checked before anything is instilled (4) Tylenol does not come powdered