Nokea
The nurse is caring for clients on a medical unit. After the shift report, which client should the nurse assess first?
- A. The 34-year-old client who is quadriplegic and cannot move his arms.
- B. The elderly client diagnosed with a CVA who is weak on the right side.
- C. The 78-year-old client with pressure ulcers who has a temperature of 102.3°F.
- D. The young adult who is unhappy with the care that was provided last shift.
Correct Answer: C
Rationale: Fever in a client with pressure ulcers suggests infection, requiring urgent assessment. Quadriplegia, weakness, and dissatisfaction are less acute.
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Which statement made to the nurse is the best evidence that the client understands the anticipated outcome of this procedure?
- A. I'm better night vision.
- B. I'll correctly identify colors.
- C. I'll see well without glasses.
- D. I'll use both eyes when reading.
Correct Answer: C
Rationale: LASIK corrects refractive errors, reducing the need for glasses.
A client who was severely burned goes to the Hubbard tank daily. Tanking sessions are limited to a half hour for which reason?
- A. A longer period of time is too tiring.
- B. Eschar becomes difficult to remove with longer soaking.
- C. Prolonged soaking causes electrolyte dilution.
- D. The water becomes too cool and may cause chilling.
Correct Answer: C
Rationale: Prolonged soaking in the Hubbard tank can lead to electrolyte dilution, risking imbalances in burn clients who are already prone to fluid and electrolyte shifts.
Which instruction to the nursing assistant is best for maintaining the client's safety and security?
- A. Let the client take your arm while walking.
- B. Take the client's arm while walking.
- C. You'll see the client in front of you and to your side.
- D. Have the client walk independently by your side.
Correct Answer: A
Rationale: Allowing the client to hold the assistant's arm provides stability and safety.
The nurse is caring for a client with complaints of a rash and itching on the face for one (1) week. Which intervention should the nurse implement first?
- A. Check for the presence of hirsutism on the face.
- B. Use the Wood’s light to visualize the rash under the black light.
- C. Determine what OTC medications the client has used on the rash.
- D. Ask the client to describe when the rash first appeared.
Correct Answer: D
Rationale: Determining rash onset provides critical history for diagnosis. Hirsutism, Wood’s light, and OTC medication history are secondary.
Assuming the following solutions are available, which one is best for the school nurse to use at this time?
- A. Tap water
- B. Sodium bicarbonate
- C. Mammalise
- D. Magnesium sulfate
Correct Answer: C
Rationale: Mammalise (likely a typo for a sterile saline solution) is the safest and most effective for eye irrigation to flush out chemicals without causing further irritation.