Nokea
The nurse is assisting in planning care for a client experiencing an acute attack of Ménière disease. Which action is a high priority to include in the plan of care?
- A. Initiate fall precautions
- B. Keep the emesis basin at bedside
- C. Provide a quiet environment
- D. Start IV fluids
Correct Answer: C
Rationale: A quiet environment (C) reduces sensory overload, a priority in Ménière disease attacks. Fall precautions (A), emesis basin (B), and IV fluids (D) are supportive but less critical.
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The nurse monitoring a client with appendicitis will expect the client to give which description of the associated abdominal pain?
- A. A burning sensation; in the upper abdomen
- B. An 8 out of 10; on the left side below the belly button
- C. Excruciating; in the lower abdomen above the right hip
- D. Intermittent; in the abdomen and right shoulder
Correct Answer: C
Rationale: Appendicitis typically causes severe pain in the right lower quadrant (C). Upper abdominal burning (A) suggests gastritis, left-sided pain (B) is atypical, and shoulder pain (D) may indicate referred pain from other conditions.
The family of an 88-year-old woman who was admitted with severe dehydration says to the nurse, 'Why don't you just tie down her arms so she won't try to get out her IV?' What is the best response for the nurse to make?
- A. Ask the physician for an order to restrain the woman
- B. Explain to the family that restraints are not allowed in the hospital unless the doctor orders them
- C. Assess the client's mental status and safety needs
- D. Tell the family that they can restrain the client, but the nurse cannot
Correct Answer: C
Rationale: Assessing mental status and safety needs determines if restraints are necessary, prioritizing least restrictive measures.
The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply.
- A. Apply a water-based lubricant to the enema tube before insertion
- B. Assist the client into left lateral position with right knee flexed
- C. Encourage the client to retain the enema for as long as possible
- D. Keep the enema solution refrigerated until ready to administer
- E. Stop the infusion briefly if the client reports abdominal cramping
Correct Answer: A,B,C,E
Rationale: Lubricating the tube (A), left lateral positioning (B), retaining the enema (C), and pausing for cramping (E) are correct for safe administration. Refrigerating the solution (D) is incorrect; it should be at body temperature.
The nurse inserts a small bore nasogastric (NG) tube and prepares to initiate enteral feedings for a hospitalized client with laryngeal cancer. Which action should the nurse take first?
- A. Crush and administer medications
- B. Dilute enteral formula as prescribed
- C. Flush the tube with 30 mL of water
- D. Verify tube placement with an x-ray
Correct Answer: D
Rationale: Verifying NG tube placement with an x-ray (D) is the first step to ensure safety before feedings or medications. Other actions follow confirmation.
The nurse is caring for a client who is receiving antibiotic therapy and develops Clostridioides difficile colitis. Which of the following infection-control precautions should the nurse implement? Select all that apply.
- A. Disinfect surfaces using a diluted bleach solution
- B. Perform hand hygiene using an alcohol-based hand sanitizer
- C. Wear a face mask
- D. Wear a protective gown
- E. Wear nonsterile gloves
Correct Answer: A,D,E
Rationale: Bleach disinfection (A), gowns (D), and gloves (E) are required for C. difficile, which is spore-forming. Alcohol sanitizers (B) are ineffective against spores, and masks (C) are not routinely needed.