Nokea
The nurse is caring for a client with Ménière's disease. The nurse stands directly in front of the client when speaking. Which of the following BEST describes the rationale for the nurse's position?
- A. This enables the client to read the nurse's lips.
- B. The client does not have to turn her head to see the nurse.
- C. The nurse will have the client's undivided attention.
- D. There is a decrease in client's peripheral visual field.
Correct Answer: B
Rationale: by decreasing movement of client's head, vertigo attacks may be decreased
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A 52-year-old woman has an appendectomy for a ruptured appendix. The nurse observes a student nurse perform a wet-to-dry dressing change on the 2-in incision.
Which of the following behaviors, if performed by the student nurse, would require an intervention by the nurse?
- A. The old dressing is saturated with sterile saline before it is removed.
- B. Dry dressings are placed over the saline-saturated gauze in the incision.
- C. Wound debris and necrotic tissue are removed with the old dressing.
- D. The gauze is saturated with sterile saline before it is packed into the incision.
Correct Answer: A
Rationale: Strategy: 'Require an intervention' indicates an incorrect action. (1) correct-should be removed dry so wound debris and necrotic tissue are removed with old dressing (2) done to protect clothing and bedding (3) purpose of wet-to-dry dressing (4) appropriate procedure
A 55-year-old woman with end-stage metastatic cancer of the breast is admitted to the hospital. It is MOST important for the nurse to
- A. suction the patient frequently.
- B. provide an air mattress.
- C. turn the patient every two hours.
- D. give the patient frequent baths.
Correct Answer: C
Rationale: Turning every two hours prevents pressure ulcers in immobile cancer patients, a priority for skin integrity. Options A, B, and D are less critical unless specifically indicated.
The nurse is caring for a client with asthma who has developed gastroesophageal reflux disease (GERD). Which of the following medications prescribed for the client may aggravate GERD?
- A. Anticholinergics
- B. Corticosteroids
- C. Histamine blocker
- D. Antibiotics
Correct Answer: A
Rationale: An anticholinergic medication will decrease gastric emptying and the pressure on the lower esophageal sphincter.
The nurse is caring for a client who had a total gastrectomy performed this morning. When the client returns to the nursing care unit, the drainage from the nasogastric tube is red. What is the nurse's best response to this?
- A. Report it immediately to the charge nurse or the physician
- B. Record the finding and continue to observe
- C. Immediately apply pressure to the operative site
- D. Place the client in Trendelenburg position
Correct Answer: A
Rationale: Red nasogastric drainage post-gastrectomy suggests bleeding, requiring immediate reporting to assess for hemorrhage.
A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. Obtaining a Guthrie Blood Test on a four-day-old infant.
- B. Massaging lotion on the abdomen of a three-year-old diagnosed with Wilm's tumor.
- C. Instructing a five-year-old asthmatic to blow on a pinwheel.
- D. Playing kickball with a 10-year-old with juvenile arthritis (JA).
Correct Answer: B
Rationale: Strategy: 'Would be considered negligence' indicates an incorrect action. (1) obtain after ingestion of protein, no later than 7 days after delivery (2) correct-manipulation of mass may cause dissemination of cancer cells (3) this exercise extends expiratory time and increases expiratory pressure (4) excellent moving and stretching exercise