Nokea
The nurse is assisting a client who has experienced a left-sided cerebral vascular accident. The client requires assistance with personal hygiene. Which intervention should the nurse do initially?
- A. provide positive feedback
- B. place hygiene items on the client's left side
- C. provide assistive devices
- D. assess abilities and level of deficit
Correct Answer: D
Rationale: Assessing the client’s abilities and deficits first guides appropriate hygiene assistance, considering left-sided neglect or weakness.
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An adolescent client hospitalized with anorexia nervosa is described by her parents as 'the perfect child.' When planning care for the client, the nurse should:
- A. Allow her to choose what foods she will eat
- B. Provide activities to foster her self-identity
- C. Encourage her to participate in morning exercise
- D. Provide a private room near the nurse's station
Correct Answer: B
Rationale: Activities fostering self-identity address the underlying issues of low self-esteem and perfectionism common in anorexia nervosa.
A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?
- A. Dulcolax suppository
- B. Docusate sodium (Colace)
- C. Methyergonovine maleate (Methergine)
- D. Bromocriptine sulfate (Parlodel)
Correct Answer: B
Rationale: Docusate sodium (Colace) is a stool softener, appropriate to prevent straining and promote healing after a proctoepisiotomy.
The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, would indicate an understanding of proper technique?
- A. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes.
- B. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing.
- C. The nurse packs wet gauze into the incision without overlapping it onto the skin.
- D. The old dressing is saturated with sterile saline before it is removed.
Correct Answer: C
Rationale: if wet dressing touches skin it could cause skin breakdown
A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:
- A. Because it is a state law
- B. To detect cardiovascular defects
- C. Because of her age
- D. To detect neurological defects
Correct Answer: D
Rationale: Serum alpha fetoprotein screening detects neural tube defects, such as spina bifida.
A primigravida with(choices truncated due to document error; assuming standard options for context) diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor's order should the nurse question?
- A. Magnesium sulfate 4 gm (25%) IV
- B. Brethine 10 mcg IV
- C. Stadol 1 mg IV push every 4 hours as needed prn for pain
- D. Ancef 2 gm IVPB every 6 hours
Correct Answer: B
Rationale: Brethine (terbutaline) is a tocolytic that can exacerbate maternal diabetes by causing hyperglycemia, so this order should be questioned in a diabetic primigravida.