Nokea
The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do?
- A. Bend at the waist
- B. Keep the feet close together
- C. Pivot on the foot proximal to the chair
- D. Use a transfer belt
Correct Answer: D
Rationale: A transfer belt ensures safety during transfers. Bending at the waist , close feet , and pivoting increase fall risk.
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The nurse is administering hygienic care to an elderly client in her home. What should the nurse wash first?
- A. Perineal area
- B. Face
- C. Upper torso
- D. Hands
Correct Answer: B
Rationale: Washing the face first during hygienic care respects client comfort and dignity, starting with a less invasive area. It also prevents cross-contamination from dirtier areas like the perineum.
The nurse is talking with the parents of a 2 year old client about nutritional choices to promote growth and development. The family observes a strict vegan diet. Which of the following information should the nurse include? Select all that apply.
- A. Diets consisting of legumes as the only protein source are sufficient for growth.
- B. Green, leafy vegetables such as cabbage and broccoli are good sources of calcium.
- C. Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake
- D. Sunlight, mushrooms, and fortified,subscribe plant based milks are good sources of vitamin D.
- E. Try to consume foods high in iron with foods high in vitamin C to increase iron absorption.
Correct Answer: B,D,E
Rationale: Leafy greens provide calcium, sunlight/mushrooms/fortified milks supply vitamin D, and vitamin C with iron enhances absorption. Legumes alone lack essential amino acids, and vegetables/fruits don't provide B12.
An elderly client is severely dehydrated. Which is the best way to assess the effectiveness of fluid restoration therapy?
- A. Assess the client's skin turgor every shift.
- B. Record weights daily.
- C. Ask the client if she is thirsty.
- D. Record all intake.
Correct Answer: B
Rationale: Daily weights provide an objective measure of fluid restoration, as 1 kg approximates 1 L of fluid. Skin turgor is less reliable in elders, thirst is subjective, and intake alone doesn't confirm absorption.
The hospital nurse administers CPR to an adult male who is found unconscious, has no pulse, and is not breathing. What is the ratio of chest compressions to respirations for one-person rescue?
- A. Fifteen chest compressions to one breath
- B. Fifteen chest compressions to two breaths
- C. Thirty chest compressions to two breaths
- D. Thirty chest compressions to two breaths
Correct Answer: C
Rationale: Current CPR guidelines recommend 30 chest compressions to 2 breaths for one-person adult resuscitation, optimizing circulation and oxygenation.
The nurse is caring for a client with a seizure disorder. Which of the following seizure precautions should the nurse implement? Select all that apply.
- A. Apply pads to the side rails.
- B. Remove all linen from the bed.
- C. Set up bedside suction equipment
- D. Prepare to apply soft limb restraints.
- E. Ensure supplemental oxygen is available.
Correct Answer: A,C,E
Rationale: Padded rails prevent injury. Suction clears airways. Oxygen supports breathing. Removing linen is unnecessary, and restraints are a last resort due to injury risk.