Nokea
The nurse is making a home visit to an elderly client during the summer. Upon arrival, the nurse notices the refrigerator and freezer doors are open as the client is using both for air conditioning. Which of the following actions by the nurse are most appropriate?
- A. instruct the client to place a fan in front of the freezer to enhance circulation of cool air
- B. hold a meeting with the client and family to advise them of the safety risks of this practice
- C. note this observation in the client's medical record, but do not discuss with the client
- D. report the incident to the nursing supervisor
Correct Answer: B
Rationale: Discussing the risks (e.g., food spoilage, electrical hazards) with the client and family promotes safety and education.
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Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence?
- A. Steadily increasing vital signs.
- B. Mild tremors and irritability.
- C. Decreased respirations and disorientation.
- D. Stomach distress and inability to sleep.
Correct Answer: A
Rationale: indication that the client is approaching delirium tremens, which can be avoided with additional sedation
A client is admitted with a diagnosis of pernicious anemia. Which of the following signs or symptoms would indicate that the client has been noncompliant with ordered B12 injections?
- A. Hyperactivity in the evening hours
- B. Weight gain of 5 pounds in 1 week
- C. Paresthesia of hands and feet
- D. Diarrhea stools several times a day
Correct Answer: C
Rationale: Pernicious anemia causes B12 deficiency, leading to neurological symptoms like paresthesia. Noncompliance with B12 injections would result in persistent or worsening paresthesia.
A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?
- A. Reinsert the protruding organ and cover with 4x4s
- B. Cover the wound with a sterile 4x4 and ABD dressing
- C. Cover the wound with a sterile saline-soaked dressing
- D. Apply an abdominal binder and manual pressure to the wound
Correct Answer: C
Rationale: Covering the eviscerated wound with a sterile saline-soaked dressing keeps the protruding organs moist and prevents infection until surgical repair.
The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is:
- A. The bladder fills more rapidly because of the medication used for the epidural.
- B. Her level of consciousness is altered.
- C. The sensation of the bladder filling is diminished or lost.
- D. She is embarrassed to ask for the bedpan that frequently.
Correct Answer: C
Rationale: Epidural anesthesia can diminish bladder sensation, increasing the risk of urinary retention, so hourly voiding is encouraged.
The client has an order for gentamycin to be administered. Which lab results should be reported to the doctor before beginning the medication?
- A. Hematocrit
- B. Creatinine
- C. White blood cell count
- D. Erythrocyte count
Correct Answer: B
Rationale: Creatinine levels indicate renal function, critical to monitor before administering gentamycin, which is nephrotoxic.