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The nurse is assisting with the admission of a client who attempted suicide after being diagnosed with end-stage kidney disease. It would be a priority for the nurse to
- A. assign the client a private room near the nurses' station
- B. explore the client's feelings about the diagnosis
- C. initiate continuous one-to-one observation
- D. perform a mental status examination
Correct Answer: C
Rationale: Continuous one-to-one observation (C) is the priority to ensure safety after a suicide attempt. Room assignment (A), exploring feelings (B), and mental status exam (D) are secondary.
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The nurse is passing a nasogastric tube into an adult. When passing the tube through the pharynx, the nurse has the client sip water through a straw. What is the purpose of this action?
- A. To prevent dehydration
- B. To divert the client's attention
- C. To close the epiglottis
- D. To lubricate the tube
Correct Answer: C
Rationale: Sipping water during nasogastric tube insertion triggers swallowing, which closes the epiglottis, preventing the tube from entering the trachea and directing it toward the esophagus.
A client with a pyloric obstruction is admitted to the hospital with vomiting. Which of the following blood gases would the nurse expect to see in the client with vomiting?
- A. $\mathrm{pH} 7.33, \mathrm{PCO}_2 30 \mathrm{~mm} \mathrm{Hg}$
- B. $\mathrm{pH} 7.50, \mathrm{PCO}_2 32 \mathrm{~mm} \mathrm{Hg}$
- C. $\mathrm{pH} 7.30, \mathrm{PCO}_2 50 \mathrm{~mm} \mathrm{Hg$
- D. $\mathrm{pH} 7.47, \mathrm{PCO}_2 40 \mathrm{~mm} \mathrm{Hg}$
Correct Answer: B
Rationale: Vomiting causes loss of hydrochloric acid, leading to metabolic alkalosis, indicated by a high pH (7.50) and normal to low PCO2.
Which test for diabetes measures the long-term management of the disease?
- A. Fasting blood sugar
- B. Glucose tolerance test
- C. Finger stick glucose test
- D. Glycosylated hemoglobin
Correct Answer: D
Rationale: Glycosylated hemoglobin (HbA1c) measures average blood glucose over 2-3 months, assessing long-term diabetes control, unlike fasting, tolerance, or finger stick tests, which are short-term.
Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply.
- A. Dimming the lights at night
- B. Leaving the television on for diversion at night
- C. Opening the window blinds/shades in the morning
- D. Scheduling interventions and activities during the day when possible
- E. Turning off equipment alarms in the client's room at night
Correct Answer: A, C, D
Rationale: Dimming lights (A), opening blinds in the morning (C), and scheduling activities during the day (D) promote circadian rhythms and rest. Leaving the TV on (B) may disrupt sleep, and turning off alarms (E) compromises safety.
The nurse reinforces teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug?
- A. Need for an eye examination
- B. Need for sunblock
- C. Risk for infection
- D. Risk for kidney injury
Correct Answer: C
Rationale: Methotrexate suppresses the immune system, significantly increasing the risk for infection (C). This is a critical teaching point to ensure the client takes precautions. Eye exams (A), sunblock (B), and kidney injury (D) are less directly associated with methotrexate's primary risks.