Nokea
The nurse is caring for a client with polycythemia vera. Which of the following actions should the nurse take? Select all that apply.
- A. Encourage increased fluid intake.
- B. Prepare the client for phlebotomy.
- C. Administer low-dose aspirin as prescribed.
- D. Teach the client to elevate the legs while sitting.
- E. Request a prescription for iron supplementation.
Correct Answer: A, B, C
Rationale: Increased fluids (A), phlebotomy (B), and aspirin (C) manage polycythemia vera by reducing blood viscosity and clotting risk. Leg elevation (D) is irrelevant, and iron supplementation (E) worsens the condition.
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The nurse is passing a nasogastric tube into an adult. When passing the tube through the pharynx, the nurse has the client sip water through a straw. What is the purpose of this action?
- A. To prevent dehydration
- B. To divert the client's attention
- C. To close the epiglottis
- D. To lubricate the tube
Correct Answer: C
Rationale: Sipping water during nasogastric tube insertion triggers swallowing, which closes the epiglottis, preventing the tube from entering the trachea and directing it toward the esophagus.
The nurse is caring for a client with hyperosmolar hyperglycemic state (HHS). The nurse should recognize which characteristic is most consistent with HHS?
- A. Abdominal pain
- B. Altered level of consciousness
- C. History of type 1 diabetes
- D. Kussmaul respirations
Correct Answer: B
Rationale: Altered consciousness (B) is a hallmark of HHS due to severe hyperglycemia and dehydration. Abdominal pain (A) and Kussmaul respirations (D) are more typical of DKA, and HHS is associated with type 2 diabetes (C).
The nurse is caring for a client with tuberculosis who is on airborne isolation precautions. The nurse can delegate which tasks to experienced unlicensed assistive personnel? Select all that apply.
- A. Alert the x-ray department about maintaining airborne isolation precautions
- B. Explain to the client why the client must wear a mask during transport to another department
- C. Post signs for airborne isolation precautions on the client's door and stock necessary equipment
- D. Remind visitors to wear a respirator mask and keep the door closed while in the client's room
- E. Talk with the family about the reasons for airborne isolation precautions in the client
Correct Answer: C, D
Rationale: Posting signs and stocking equipment (C) and reminding visitors about precautions (D) are within UAP scope. Alerting departments (A), explaining to the client (B), and educating family (E) require nursing judgment.
The nurse is caring for a client who had a colostomy. Which comment by the client indicates that she is showing an interest in learning about her colostomy?
- A. Why did this problem have to happen to me?'
- B. What is the bag of water for?'
- C. When will I get rid of this thing?'
- D. The doctor didn't really do a colostomy.'
Correct Answer: B
Rationale: Asking about the bag's purpose shows curiosity and readiness to learn about colostomy care. Other comments reflect denial, frustration, or lack of engagement.
The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which finding requires intervention by the nurse?
- A. Contraction duration of 95 seconds
- B. Contraction frequency of every 3 minutes
- C. Contraction intensity of 45 mm Hg
- D. Uterine resting tone of 10 mm Hg
Correct Answer: A
Rationale: Contraction duration of 95 seconds (A) is too long and may reduce fetal oxygenation, requiring intervention. Frequency (B), intensity (C), and resting tone (D) are within normal limits.