Nokea
The nurse is caring for a client with mild Alzheimer disease who is agitated after eating breakfast. The client states, 'I am hungry. You did not feed me.' Which of the following actions should the nurse take?
- A. Offer the client finger foods to eat.
- B. Provide the client with additional food at mealtimes.
- C. Tell the client that the client may have a snack before lunch.
- D. Ask the dietician to evaluate the client's daily calorie requirements
Correct Answer: C
Rationale: For an Alzheimer client with agitation and false hunger claims, offering a snack before lunch calms the client without overfeeding. Finger foods or extra meals may not address agitation, and a dietician evaluation is less immediate.
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The nurse in a clinic is caring for an 8-month-old client with a new diagnosis of bronchiolitis due to respiratory syncytial virus. Which of the following instructions should the nurse provide to the parent?
- A. Administration of a cough suppressant and an antihistamine
- B. Prophylactic treatment of family members
- C. Temporary cessation of breastfeeding
- D. Use of saline drops and a bulb syringe to suction nares
Correct Answer: D
Rationale: For bronchiolitis due to RSV, saline drops and bulb syringe suctioning help clear nasal passages, improving breathing. Cough suppressants and antihistamines are not recommended as they may suppress necessary cough or cause sedation. Prophylactic treatment is not standard for family members unless immunocompromised, and breastfeeding should continue to provide antibodies.
Laboratory Reference Range
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L)
The nurse has received information from unlicensed assistive personnel about assigned client situations. Which of the following situations should the nurse address first?
- A. Client who has type 1 diabetes mellitus and a fasting capillary blood glucose level of 90 mg/dL (5.0 mmol/L)
- B. client who is collecting a 24-hour urine specimen and discarded the last void by mistake
- C. client who is requesting clarification about the diagnostic procedure that is scheduled to begin in 4 hours
- D. client who was recently admitted to a room that has a full sharps disposal container on the wall
Correct Answer: D
Rationale: A full sharps container poses an immediate safety hazard and must be addressed first. Normal glucose , a discarded void , and procedure clarification are less urgent.
In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube?
- A. Cardizem SR tablet (diltiazem)
- B. Lanoxin liquid
- C. Os-cal tablet (calcium carbonate)
- D. Tylenol liquid (acetaminophen)
Correct Answer: A
Rationale: Cardizem SR is a 'sustained-release' drug form. Sustained release (controlled-release, long-acting) drug formulations are designed to release the drug over an extended period of time. If crushed, as would be required for gastrostomy tube administration, sustained-release properties and blood levels of the drug will be altered. The provider must substitute another medication.
A client is experiencing an exacerbation of chronic lower back pain after working in the yard all weekend. The nurse should reinforce the primary importance of which nonpharmacologic intervention for acute muscle pain?
- A. Heating pad
- B. Positioning for comfort
- C. Rest from pain-aggravating activities
- D. Stretching exercises
Correct Answer: C
Rationale: For acute lower back pain, rest from aggravating activities is primary to prevent further strain. Heat and positioning are helpful but secondary, and stretching may worsen acute pain.
The nurse is screening clients for those at risk for developing oral candidiasis. The nurse should recognize the client at highest risk for developing oral candidiasis is a client who
- A. has asthma and uses an albuterol nebulizer once a week
- B. has dental braces and consumes several high sugar beverages daily
- C. is HIV positive and has been receiving antibiotics daily for the past 3 months
- D. has a decreased serum albumin level after consuming a vegan diet for the past 6 months
Correct Answer: C
Rationale: An HIV-positive client on long-term antibiotics is at highest risk for oral candidiasis due to immunosuppression and microbial imbalance. Albuterol use , sugary drinks , and low albumin are less significant risk factors.