Nokea
The nurse is preparing a client environment that will reduce the chance of falls. Which action is appropriate?
- A. Keep the half side rails down on the side the client uses to get out of bed.
- B. Keep the lights down since glare bothers some clients.
- C. Call housekeeping to clean up the spilled water.
- D. Make sure that a path is cleared to assist the client when walking.
Correct Answer: D
Rationale: Clearing a path reduces tripping hazards, a key environmental modification to prevent falls.
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The nurse assesses the development of a three-month-old boy in the well-baby clinic.
- A. Which behavior in a three-month-old boy would be unexpected?
- B. The boy holds his head erect when sitting on the examination table.
- C. The boy tries to grasp a toy just out of reach.
- D. The boy turns his head to try to locate a sound.
- E. The boy smiles spontaneously when he sees his mother.
Correct Answer: B
Rationale: Grasping for objects out of reach is unexpected until around 6 months of age. Holding the head erect, turning toward sounds, and spontaneous smiling are developmentally appropriate for a three-month-old.
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Calcium level of 8.0 mg/dL.
- B. Temperature of 99.5°F (37.5°C).
- C. Heart rate of 100 bpm.
- D. Pain at the incision site.
Correct Answer: A
Rationale: A calcium level of 8.0 mg/dL indicates hypocalcemia, a serious complication post-thyroidectomy due to parathyroid damage, risking tetany or seizures. Options B, C, and D are expected: slight fever, tachycardia, and incision pain are common postoperatively.
The nurse is caring for an adult who had a nephrectomy this morning. Because of the location of the surgery, the nurse knows that the client is at increased risk for which of the following?
- A. Thrombophlebitis
- B. Wound infection
- C. Atelectasis
- D. Footdrop
Correct Answer: C
Rationale: Nephrectomy involves flank incision near the diaphragm; postoperative pain limits deep breathing, increasing atelectasis risk. Thrombophlebitis, infection, or footdrop are less specific to the site.
A woman is in the clinic complaining of urinary frequency, urgency, and pain on urination. Orders include a urine for culture and administration of sulfisoxazole (Gantrisin) and phenazopyridine (Pyridium.) Which action should the nurse take first?
- A. Obtain a clean catch urine from the client.
- B. Ask the client if she is allergic to sulfa drugs.
- C. Administer the sulfisoxazole (Gantrisin).
- D. Administer the phenazopyridine (Pyridium).
Correct Answer: B
Rationale: Checking for sulfa allergies is critical before administering sulfisoxazole, as allergies can cause severe reactions, prioritizing safety.
A client recovering from acute pancreatitis is started on solid food. Which of the following foods should be avoided?
- A. Vanilla custard
- B. Sponge cake
- C. Sliced peaches
- D. Cereal
Correct Answer: A
Rationale: Vanilla custard is high in fat, which can stimulate pancreatic enzyme release and worsen pancreatitis. Sponge cake, peaches, and cereal are lower in fat and safer.