Nokea
The nurse is caring for an adult who has had nausea and vomiting for several days and is being admitted to the nursing care unit. The client can follow directions. IV fluids were started in the emergency department. Which action is the highest priority for the nurse at this time?
- A. Offer oral fluids every hour.
- B. Turn every two hours.
- C. Monitor urine output.
- D. Put client in a supine position.
Correct Answer: C
Rationale: Monitoring urine output is critical to assess hydration status and kidney function in a client with prolonged nausea and vomiting, as dehydration is a major risk. IV fluids address dehydration, making oral fluids less urgent, and turning or positioning are secondary.
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A client who is receiving a tube feeding around the clock.
Which of the following nursing actions is MOST appropriate?
- A. Rinse the bag and change the formula every four hours.
- B. Rinse the bag and change the formula every shift.
- C. Change the bag and formula every shift.
- D. Rinse the bag and change the formula every two hours.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-there is an increased growth of organisms after four hours (2) inappropriate due to increased organism growth (3) inappropriate due to increased organism growth (4) not a necessary action to maintain asepsis
The nurse is to start oxygen therapy via nasal cannula. Which action is correct?
- A. Set the oxygen at 12 L/min.
- B. Lubricate the cannula with petrolatum before inserting.
- C. Give 100% oxygen by mask before inserting.
- D. Insert the cannula 1 cm into the nostrils.
Correct Answer: D
Rationale: Inserting the cannula 1 cm into the nostrils ensures proper oxygen delivery. High flow rates, petrolatum, or mask pre-oxygenation are incorrect.
Which action is most likely to ensure the safety of the nurse while making a home visit?
- A. Observe no evidence of weapons in the home during the visit
- B. Prior to the visit, review the client's record for any previous entries about violence
- C. Remain alert at all times and leave if cues suggest the home is not safe
- D. Carry a cell phone, pager and/or hand held alarm for emergencies
Correct Answer: C
Rationale: Remain alert at all times and leave if cues suggest the home is not safe. No person or equipment can guarantee nurses' safety, although the risk of violence can be minimized. Before making initial visits, review referral information carefully and have a plan to communicate with agency staff. Schedule appointments with clients. When driving into an area for the first time, note potential hazards. Observe surroundings when parking, walking to the client's door, making the visit, walking back to the car, and driving away. LISTEN to clients. If they tell you to leave, do so.
A comatose patient who is incontinent.
The nurse should intervene if which of the following actions is noted?
- A. The nurse assistant answers the phone while wearing gloves.
- B. The nursing assistant log rolls the patient to provide back care.
- C. The nursing assistant places an incontinence pad under the patient.
- D. The nursing assistant positions the patient on the left side, head elevated.
Correct Answer: A
Rationale: Strategy: 'Nurse should intervene' indicates that you are looking for an incorrect action. (1) correct-contaminated gloves should be removed before answering the phone (2) correct way to roll a patient to maintain proper alignment (3) appropriate to use incontinence pad for this patient (4) appropriate position to prevent aspiration and protect the airway
The nurse is assessing a dark-skinned client with anemia. Which part of the body would the nurse assess for pallor?
- A. Nail beds
- B. Hard palate
- C. Sclera
- D. Buccal mucosa
Correct Answer: D
Rationale: The buccal mucosa is reliable for assessing pallor in dark-skinned clients, as skin pigmentation may mask changes elsewhere.