Nokea
The nurse is caring for a 42-year-old client who has a do not resuscitate (DNR) order on the chart. The client tells the nurse, 'I've changed my mind about the DNR. I would like to cancel that and be given whatever care is needed to keep me alive.' Which response by the nurse is correct?
- A. I will notify your health care provider right away.'
- B. I'm glad to hear this. You shouldn't be a DNR at your age.'
- C. Let me call your family and tell them you have changed your mind.'
- D. You cannot change a DNR once it's on your chart. It is a legal document.'
Correct Answer: A
Rationale: A DNR can be revoked by the client at any time. Notifying the provider ensures the change is documented and followed.
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A 5-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:
- A. Preventing infection
- B. Administering antipyretics
- C. Keeping the skin free of moisture
- D. Limiting oral fluid intake
Correct Answer: A
Rationale: Atopic dermatitis involves inflamed skin prone to infection, so preventing infection through gentle skin care and monitoring is a priority.
The nurse is monitoring a client’s EKG strip and notes coupled premature ventricular contractions greater than 10 per minute. The nurse should expect to administer which of the following?
- A. Atropine sulfate (Atropine) IV.
- B. Isoproterenol (Isuprel) IV.
- C. Verapamil (Calan) IV.
- D. Lidocaine hydrochloride (Xylocaine) IV.
Correct Answer: D
Rationale: Lidocaine is the drug of choice for frequent premature ventricular contractions (PVC) occurring in excess of 6-10 per minute; for coupled PVCs or for a consecutive series of PVCs that may result in ventricular tachycardia
A client is admitted to the medical-surgical unit with a report of severe hematemesis. The nurse should give priority to:
- A. Performing an assessment
- B. Obtaining a blood permit
- C. Initiating an IV with a large-bore needle
- D. Inserting an NG tube
Correct Answer: C
Rationale: Severe hematemesis indicates significant bleeding, requiring immediate IV access with a large-bore needle for fluid and blood resuscitation to stabilize the client.
If the nurse is providing education to a male client who is HIV positive, which of the following information should the nurse include? Select all that apply.
- A. Need to use condoms for every sexual encounter.
- B. Need to tell sexual or needle-sharing partners about HIV status.
- C. Signs and symptoms indicating increased viral load and infections.
- D. Importance of maintaining a healthy lifestyle.
- E. Availability of support groups.
Correct Answer: A,B,C,D,E
Rationale: HIV education includes condoms (A), disclosing status (B), monitoring symptoms (C), healthy lifestyle (D), and support groups (E) to manage disease and prevent transmission.
A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?
- A. Insert 10 mL of air in the NG tube and listen over the abdomen with a stethoscope
- B. Clamp the tube while listening to the abdomen with a stethoscope
- C. Irrigate the tube with 30 mL of NS while auscultating the abdomen
- D. Turn the suction on high and auscultate over the naval area
Correct Answer: B
Rationale: Clamping the NG tube prevents suction noise from interfering with auscultation, allowing accurate assessment of bowel sounds.