Nokea
The nurse is giving home care to a 69-year-old client who has severe arthritis. Which comment made by the client would indicate to the nurse that the client is experiencing normal changes associated with the aging process?
- A. I have such a hard time with the pain in my feet and knees.
- B. I have had loose stools for the last few months.
- C. My children say I keep my apartment too warm.
- D. I have a hard time at night because the lights are all big and fuzzy.
Correct Answer: C
Rationale: Feeling cold and preferring a warmer environment is a normal age-related change due to decreased thermoregulation. Pain, loose stools, and visual changes may indicate pathology requiring further investigation.
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A practical nurse is collaborating with a registered nurse educator to develop materials for a hospital-wide campaign about zero tolerance for lateral violence and bullying among staff. Which actions should staff members be encouraged to perform if they experience workplace violence? Select all that apply.
- A. Document the interactions with the bully
- B. Ignore the bully's comments, remarks, and allegations
- C. Observe interactions between the bully and other colleagues
- D. Report the violent incidents to the hospital administrator
- E. Tell the bully you will not tolerate the unprofessional behavior
Correct Answer: A, C, D, E
Rationale: Documenting incidents (A), observing patterns (C), reporting to administration (D), and confronting unprofessional behavior (E) are proactive steps to address bullying. Ignoring comments (B) may allow the behavior to persist.
A nurse is reinforcing teaching to a client that breastfeeds who has been diagnosed with mastitis of the right breast. Which of the following instructions should be included? Select all that apply.
- A. Cease breastfeeding from right breast
- B. Increase oral fluid intake
- C. Reduce frequency of feeds to every 8 hours in right breast
- D. Take ibuprofen as needed for pain
- E. Use a tight-fitting underwire bra 24 hours per day
Correct Answer: B, D
Rationale: Increased fluids (B) and ibuprofen (D) manage dehydration and pain. Ceasing breastfeeding (A) or reducing feeds (C) can worsen mastitis, and tight bras (E) may increase discomfort.
The nurse is caring for a hospitalized client. Which is the best example of narrative documentation to provide legal malpractice protection for the nurse after an adverse event?
- A. Client found on floor this morning at 6:50 AM. No verbalized symptoms. I think client tripped over a cord. Client instructed on safety during ambulation.'
- B. Client reports IV pole hit head at 7:30 AM. Denies pain. IV pole removed for client safety. Will continue to monitor. Health care provider (HCP) notified.'
- C. IV site in right hand is red and swollen at 9:30 AM. IV line removed, bleeding controlled, and warm compress administered at 9:40 AM. Will monitor for swelling and pain every hour.'
- D. Package of green leaves found in client drawer at 1:00 PM. Client acting suspicious at 2:00 PM. HCP notified. Will call security. Client has multiple tattoos and piercings.'
Correct Answer: C
Rationale: Detailed, objective documentation (C) with times, actions, and follow-up plans provides the best legal protection. Options A, B, and D include assumptions, vague details, or irrelevant information.
When giving an intramuscular injection to an infant. Which of the following sites is preferred?
- A. Ventrogluteal region
- B. Deltoid
- C. Vastus lateralis
- D. Dorsogluteal region
Correct Answer: C
Rationale: Vastus lateralis is the ideal choice for infants.
Laboratory reference ranges
Glucose (fasting)
Infant – Within 24 hours after birth
≥40 mg/dL (2.2 mmol/L)
The nurse is caring for assigned newborns. Which of the following newborns should the nurse check first?
- A. a newborn who was delivered 30 minutes ago and has bilateral crackles
- B. a newborn who was delivered 45 minutes ago and has asymmetric arm movement when the Moro reflex is tested
- C. a newborn who was delivered 6 hours ago and has a respiratory rate of 52/min
- D. a newborn who was delivered 12 hours ago, is jittery, and has a serum glucose level of 38 mg/dL (2.1 mmol/L)
Correct Answer: D
Rationale: A glucose level of 38 mg/dL with jitteriness (D) indicates hypoglycemia, a critical condition requiring immediate intervention. Crackles (A), asymmetric Moro reflex (B), and respiratory rate of 52 (C) are less urgent.