Nokea
The nurse is caring for a client who is to be on bed rest for two weeks. What should the nurse do to prevent atelectasis?
- A. Encourage the client to deep breathe and cough every two hours
- B. Encourage the client to flex and extend her feet every two hours
- C. Apply antiembolism stockings as ordered
- D. Perform range-of-motion exercises several times a day
Correct Answer: A
Rationale: Deep breathing and coughing expand the lungs, preventing atelectasis in bedridden clients. Foot exercises, stockings, and ROM prevent other complications but not atelectasis.
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Which action is most likely to ensure the safety of the nurse while making a home visit?
- A. Observe no evidence of weapons in the home during the visit
- B. Prior to the visit, review the client's record for any previous entries about violence
- C. Remain alert at all times and leave if cues suggest the home is not safe
- D. Carry a cell phone, pager and/or hand held alarm for emergencies
Correct Answer: C
Rationale: Remain alert at all times and leave if cues suggest the home is not safe. No person or equipment can guarantee nurses' safety, although the risk of violence can be minimized. Before making initial visits, review referral information carefully and have a plan to communicate with agency staff. Schedule appointments with clients. When driving into an area for the first time, note potential hazards. Observe surroundings when parking, walking to the client's door, making the visit, walking back to the car, and driving away. LISTEN to clients. If they tell you to leave, do so.
The charge nurse is planning assignments on a medical unit. The client with should be assigned to the unlicensed assistive personnel (UAP).
- A. difficulty swallowing after a mild stroke
- B. an order of enemas until clear prior to colonoscopy
- C. an order for a post-op abdominal dressing change
- D. transfer orders to a long term facility
Correct Answer: B
Rationale: The UAP can be assigned routine tasks which have predictable outcomes, such as administering enemas.
A client with acute leukemia has developed oral ulcerations. The nurse can increase the client's comfort by suggesting that he:
- A. Avoid brushing his teeth until the ulcers heal.
- B. Rinse his mouth frequently with normal saline.
- C. Rinse his mouth frequently with hydrogen peroxide.
- D. Cleanse his teeth and mouth with lemon and glycerin swabs.
Correct Answer: B
Rationale: Normal saline rinses are gentle and help keep the mouth clean without irritating oral ulcerations.
The nurse is preparing a client for a skin biopsy.
Which of the following client statements should the nurse report to the physician?
- A. I've been taking aspirin for my sore knees.'
- B. Using lotion has helped my dry skin.'
- C. I went to the tanning salon yesterday.'
- D. I had a big breakfast this morning.'
Correct Answer: A
Rationale: Strategy: Determine how the statements relate to skin biopsy. (1) correct-aspirin compounds can increase bleeding time and should not be taken prior to a surgical procedure (2) does not affect the accuracy or results of the biopsy (3) does not affect the accuracy or results of the biopsy (4) does not affect the accuracy or results of the biopsy
The nurse is providing home care to an elderly woman who had a cerebrovascular accident (CVA) and has right-sided hemiplegia. She is living with her daughter. Which observation indicates that the family needs more instruction?
- A. The client's arms and legs are exercised every day.
- B. The daughter gets her mother out of bed several times a day.
- C. The client is given a shower every other day.
- D. The daughter puts the chair on the right side of the bed when getting her mother out of bed.
Correct Answer: D
Rationale: Placing the chair on the right (paralyzed) side hinders safe transfers; it should be on the unaffected left side, indicating a need for further instruction.