Nokea
The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)?
- A. Keep the room at a comfortable temperature.
- B. Maintain the client in a semi-Fowler's position.
- C. Ensure oral suction is available.
- D. Provide frequent mouth care.
Correct Answer: C
Rationale: Oral suction prevents aspiration of secretions during seizures, ensuring airway patency and safety.
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A client receives a prescription for 1 L of lactated Ringers to be infused IV over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)
- A. 125 mL/hr
Correct Answer: A
Rationale: Calculation: 1000 mL ÷ 8 hours = 125 mL/hr, ensuring accurate infusion rate.
A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)
- A. Remove the medication from the dispensing system.
- B. Compare the client's wristband to the medication administration record.
- C. Document administration of the medication.
- D. Open the medication package.
- E. Obtain the client's apical heart rate.
Correct Answer: E,A,B,D,C
Rationale: The sequence ensures safety and accuracy: checking the apical heart rate first prevents administration if contraindicated; removing the medication , verifying patient identity , opening the package , and documenting follow standard medication administration protocols.
History and Physical
Nurses' Notes
Orders
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.
- A. Administer additional nebulizer treatment as ordered.
- B. Take and monitor vital signs.
- C. Apply a nonrebreather oxygen mask.
- D. Increase oxygen flow.
- E. Raise the head of the bed.
- F. Provide client incentive spirometer and instruct on use.
Correct Answer: A,B,D,E
Rationale: Additional nebulizer treatment targets persistent wheezing, monitoring vital signs tracks response, increasing oxygen flow addresses low saturation, and raising the bed aids breathing. A nonrebreather is unnecessary at this stage, and incentive spirometry (F) is not indicated during an acute attack.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Do your family members share combs and brushes?
- B. Do you have any dry patches on your feet and hands?
- C. Has everyone at home already had varicella?
- D. Have the antifungal creams been effective?
Correct Answer: C
Rationale: Asking about varicella history assesses the risk of chickenpox transmission to susceptible household members from herpes zoster.
The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?
- A. Get an influenza vaccine every year as soon as available.
- B. Using salt, herbs, and spices will Improve the flavor of foods.
- C. Restrict alcoholic beverages to no more than 1-2 per week.
- D. Eat a protein snack 30 minutes before any exercise workout.
Correct Answer: B
Rationale: Using herbs and spices reduces reliance on sugars and fats, supporting glycemic control in diabetes.