Nokea
The nurse is caring for a client with uremic frost. The nurse is aware that uremic frost is often seen in clients with:
- A. Severe anemia
- B. Arteriosclerosis
- C. Liver failure
- D. Parathyroid disorder
Correct Answer: C
Rationale: Uremic frost, a powdery deposit on the skin, is associated with end-stage renal failure, not liver failure, but the options suggest a contextual error; renal failure is the intended association.
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Which statement is incorrect regarding the Federal Nursing Home Reform Act from the Omnibus Budget Reconciliation Act of 1987 (OBRA '87)?
- A. the right to be free of unnecessary chemical restraints
- B. the right to choose a personal physician
- C. the right to access medical records
- D. the right to organize hospital personnel within a union
Correct Answer: D
Rationale: OBRA '87 does not include the right to organize hospital personnel into a union. Other rights are part of the act.
The nurse must administer in one syringe a combined dose of two different insulins from two vials. Place the steps (Roman numerals) in the correct order.
- A. Cleanse tops of vials.
- B. Inject air into vial 1.
- C. Withdraw medication from vial 1.
- D. Change needles.
- E. Withdraw medication from vial 2.
- F. Inject air into vial 2.
Correct Answer: A,B,F,C,E
Rationale: The correct order is: Cleanse vials (I), inject air into vial 1 (II), inject air into vial 2 (VI), withdraw from vial 1 (III), withdraw from vial 2 (V). Changing needles (IV) is not standard.
The nurse is preparing to administer the first dose of IV antibiotic to the client. Halfway through the infusion, the nurse realizes that the antibiotic dosage is not the same as ordered by the health care provider. Which action should the nurse take first?
- A. stop the infusion
- B. fill out an incident form
- C. notify the health care provider
- D. only give part of the antibiotic to obtain the correct dose
Correct Answer: A
Rationale: Stopping the infusion is the priority to prevent harm from an incorrect dose, followed by notifying the provider and completing an incident report.
A client requires insertion of a nasogastric tube. When preparing the client for the procedure, the nurse should place the client in which of the following positions?
- A. High Fowler's position with the head tilted forward.
- B. High Fowler's position with the head tilted backward.
- C. Semi-Fowler's position with the head in a neutral position.
- D. Semi-Fowler's position with the head tilted backward.
Correct Answer: A
Rationale: High Fowler's position with the head tilted forward (A) facilitates nasogastric tube insertion by aligning the esophagus and reducing the risk of aspiration. Tilting the head backward (B, D) or using a neutral position in semi-Fowler's (C) is less effective for this procedure.
A neonatal nurse assesses a premature newborn baby using the Apgar score. All of the following assessments are given a score EXCEPT
- A. grimace.
- B. pulse.
- C. activity.
- D. rooting.
- E. appearance.
Correct Answer: D
Rationale: The Apgar score evaluates appearance, pulse, grimace, activity, and respiration. Rooting (a feeding reflex) is not part of the Apgar assessment.