Nokea
The nurse is instructing an unlicensed assistive personnel on the prevention of postoperative pulmonary complications. Which of the following statements indicates that the assistant has understood the nurse's instructions?
- A. I will turn the client every 4 hours.'
- B. I will keep the client's head elevated.'
- C. I should suction the client every 2 hours.'
- D. I will have the client take 5 to 10 deep breaths every hour.'
Correct Answer: D
Rationale: Deep breathing exercises hourly prevent atelectasis and promote lung expansion, key to preventing pulmonary complications.
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The nurse is caring for a child with a head injury. Place the following assessments in order of priority, starting with the nursing assessment the nurse should perform first.
- A. Vital signs.
- B. Decreased urine output.
- C. Level of consciousness.
- D. Motor strength.
Correct Answer: C,A,D,B
Rationale: Level of consciousness is the priority to assess neurological status, followed by vital signs for stability, motor strength for deficits, and urine output for systemic effects.
Identify this cardiac rhythm strip. Fill in the blank. A. Idioventricular Rhythm B. Bundle Branch Block C. Sinus bradycardia D. Atrial Flutter
- B. Idioventricular Rhythm
- C. Bundle Branch Block
- D. Sinus bradycardia
- E. Atrial Flutter
Correct Answer: C
Rationale: Sinus bradycardia is characterized by a regular rhythm with a rate below 60 beats per minute, assuming the strip shows this pattern.
The nurse is teaching a client with a new diagnosis of type 2 diabetes about foot care. Which of the following instructions should be included? Select all that apply.
- A. Inspect feet daily for cuts or sores.
- B. Wear well-fitting shoes.
- C. Soak feet in hot water daily.
- D. Apply lotion between the toes.
- E. Trim toenails straight across.
Correct Answer: A, B, E
Rationale: Daily inspection, well-fitting shoes, and straight toenail trimming prevent complications. Hot water and lotion between toes increase infection risk.
The nurse is assessing a client with suspected hypovolemic shock. Which finding is most indicative?
- A. Tachycardia
- B. Hypertension
- C. Warm, dry skin
- D. Bradypnea
Correct Answer: A
Rationale: Tachycardia is an early sign of hypovolemic shock as the body compensates for reduced blood volume by increasing heart rate.
Betamethasone (Celestone) syrup 0.9 mg has been ordered. It is available in a 0.6 mg/5 mL solution. How many milliliters should the nurse administer?
- A. 5 mL
- B. 7.5 mL
- C. 10 mL
- D. 2.5 mL
Correct Answer: B
Rationale: To calculate: (0.9 mg / 0.6 mg) × 5 mL = 7.5 mL.