Nokea
The nurse is caring for a client who has dentures. Which action by the nurse is not appropriate?
- A. Place a washcloth in the bottom of the sink before cleaning the dentures.
- B. Brush the dentures with toothpaste.
- C. Rinse the dentures with hydrogen peroxide.
- D. Remove the dentures from the mouth for cleaning.
Correct Answer: C
Rationale: Hydrogen peroxide can damage dentures; rinsing with water or denture cleaner is appropriate, making this action incorrect.
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The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client?
- A. Ask the client and family if they are satisfied with the care given
- B. Determine the home health aide is care to a consistent with the plan of care
- C. Investigate if the home health aide is prompt and stays an appropriate length of time for care
- D. Check the documentation of the aide for appropriateness and comprehensiveness
Correct Answer: B
Rationale: Although the nurse must complete all of the above responsibilities, evaluation of an adherence to the plan of care is the first priority. The plan of care is based on the reason for referral, provider's orders, the initial nursing assessment, the client's responses to the planned interventions, and the client's and family's feedback or inquiries.
The nurse is assessing a client immediately after an exploratory laparotomy. Which of the following nursing observations would relate to the complication of inTest inal obstruction?
- A. Protruding soft abdomen with frequent diarrhea.
- B. Distended abdomen with ascites.
- C. Minimal bowel sounds in all four quadrants.
- D. Distended abdomen with complaints of pain.
Correct Answer: D
Rationale: if an obstruction is present, the abdomen will become distended and painful
An 18-month-old is brought by her father to the well-baby clinic for a routine immunization. Just before the nurse gives the child the injection, the toddler begins to cry.
Which of the following comments by the nurse is the MOST appropriate?
- A. Don't cry. It will be better if you try to behave.'
- B. I know you are frightened. It will be over with soon.'
- C. A big girl like you shouldn't cry. It's only going to hurt a little.'
- D. Please stop crying. There is nothing to be afraid of.'
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication (1) nontherapeutic, doesn't respond to feeling tone and tells child what to do (2) correct-doesn't minimize child's reaction, responds to feeling tone (3) nontherapeutic, minimizes child's reaction (4) nontherapeutic, minimizes child's reaction, should indicate it is OK to feel afraid
The nurse is caring for a client who is postoperative day 1 after a total hip replacement. Which of the following actions is the PRIORITY?
- A. Encourage the client to use the incentive spirometer.
- B. Administer pain medication as needed.
- C. Position the client with the legs abducted.
- D. Check the surgical dressing for drainage.
Correct Answer: C
Rationale: Positioning with legs abducted prevents hip dislocation, a critical complication post-hip replacement. Options A, B, and D are important but secondary: incentive spirometry prevents pneumonia, pain management supports recovery, and dressing checks monitor bleeding.
The nurse has just received report from the previous shift.
Which of the following patients should the nurse see FIRST?
- A. An elderly woman, 8-hours postoperative, following an open-reduction and internal fixation of the right hip.
- B. An elderly man admitted 4 hours ago with status asthmaticus.
- C. A middle-aged man admitted 2 days ago with pneumonia who has a temperature of 101.2°F (38.4°C).
- D. A middle-aged woman who suffered a myocardial infarction (MI) 3 days ago.
Correct Answer: B
Rationale: Strategy: Determine the least stable client. (1) leg needs to be abducted at all times, ice to operative site, turn patient as ordered (2) correct-life-threatening condition which can last longer than 24 hours, constantly monitor client (3) requires follow-up, assess breath sounds (4) monitor vital signs, I and O, teach to modify lifestyle (stop smoking, reduce stress, modify intake of calories, fat, and salt)