Nokea
The nurse is performing a sterile dressing change for a client when a second client begins yelling for pain medication. Which of the following actions should the nurse take?
- A. Ask unlicensed assistive personnel (UAP) to take the second client’s vital signs and report back immediately
- B. Direct UAP to ask the second client to rate the pain on a 0-10 scale and report back immediately
- C. Inform UAP to tell the second client that the nurse will be there soon and complete the sterile dressing change
- D. Interrupt the dressing change to medicate the second client
Correct Answer: C
Rationale: Completing the sterile dressing change maintains sterility and infection control, while informing the UAP to reassure the second client ensures their needs are addressed promptly without compromising the first client’s care.
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The nurse is reviewing recommended dietary modifications with the parents of a 6-month-old client with phenylketonuria. Which of the following information should the nurse include? Select all that apply.
- A. A low-phenylalanine diet is required
- B. Meat and dairy products should not be introduced into the diet
- C. Phenylketonuria is self-limiting and dietary modifications are temporary
- D. Specially prepared infant formula is necessary
- E. Tyrosine should be removed from the diet
Correct Answer: A,B,D
Rationale: Phenylketonuria requires a lifelong low-phenylalanine diet, avoiding meat and dairy, and using special formula to prevent neurological damage. It is not self-limiting, and tyrosine is needed, not removed.
The summer camp nurse and parent of a 9-year-old with juvenile idiopathic arthritis (JIA) are discussing appropriate physical activities for the child. Which of the following activities should be included? Select all that apply.
- A. Dodgeball
- B. Reading a book
- C. Stationary bicycling
- D. Swimming
- E. Yoga
Correct Answer: C,D,E
Rationale: Stationary bicycling, swimming, and yoga are low-impact, joint-friendly activities for JIA. Dodgeball risks joint stress, and reading, while safe, is not a physical activity.
A client with a C3 spinal cord injury has a headache and nausea. The client’s blood pressure is 170/100 mm Hg. How should the nurse respond initially?
- A. Administer PRN analgesic medication
- B. Administer PRN antihypertensive medication
- C. Lower the head of the bed
- D. Palpate the client’s bladder
Correct Answer: D
Rationale: Headache, nausea, and hypertension in a C3 injury suggest autonomic dysreflexia, often triggered by bladder distension. Palpating the bladder identifies and addresses the cause. Medications and bed positioning are secondary.
A laboring woman has been pushing for one hour and is not making progress. The nurse knows that which of the following could hinder the descent of the fetus in the second stage of labor?
- A. A full bladder
- B. Paracervical block given during the first stage of labor
- C. Mother placed in a side-lying position
- D. Fetus in LOA (left occiput anterior) position
Correct Answer: A
Rationale: A full bladder obstructs fetal descent by occupying pelvic space, hindering labor progress, unlike anesthesia, positioning, or optimal fetal position.
Which incidence should be documented on an unusual incident report?
- A. The client leaves the hospital against the doctor's advice.
- B. The client develops a fever after receiving a blood transfusion.
- C. The client reports an upset stomach after taking an antibiotic.
- D. The client falls in her bathroom.
Correct Answer: D
Rationale: A fall is an unusual incident requiring documentation due to potential injury and liability. Leaving AMA, transfusion fever, or upset stomach are notable but less likely to require an incident report.