Nokea
The nurse is preparing to administer ear drops to an adult client. It would require follow-up if the nurse
- A. instills the ear drops at room temperature
- B. instills the ear drops by placing the dropper into the ear canal
- C. pulls the pinna of the client's ear up and back before instillation
- D. places a cotton ball loosely in the outermost auditory canal after instillation
Correct Answer: B
Rationale: Placing the dropper into the ear canal risks injury and contamination. Ear drops should be instilled by holding the dropper above the canal. Other actions are correct: room-temperature drops prevent discomfort, pulling the pinna straightens the canal, and a cotton ball retains the medication.
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A home care client is scheduled for dialysis. He asks the nurse if he should take his antihypertensive medication before going for dialysis. How should the nurse respond?
- A. He should take all regularly scheduled medications.
- B. Antihypertensives should not be taken before dialysis because the blood pressure drops during dialysis.
- C. He should check with the physician because it varies from person to person.
- D. He should take it with him and take it if his blood pressure rises during the treatment.
Correct Answer: B
Rationale: Antihypertensives are often held before dialysis to prevent hypotension, as dialysis can lower blood pressure. Routine administration, physician checks, or conditional dosing are less appropriate.
A client is admitted for COPD. Which findings would require the nurse's immediate attention?
- A. Nausea and vomiting
- B. Restlessness and confusion
- C. Low-grade fever and cough
- D. Irritating cough and liquefied sputum
Correct Answer: B
Rationale: Restlessness and confusion. Respiratory failure may be signaled by excessive somnolence, restlessness, aggressiveness, confusion, central cyanosis and shortness of breath. When these findings occur, arterial blood gases (ABGs) should be obtained.
Written instructions to pregnant women include instructions to perform Kegel exercises. One of the women asks the nurse why these exercises are important. The nurse should reply that the purpose of these exercises is to:
- A. increase circulation to the uterus.
- B. strengthen the muscles of the pelvic floor.
- C. prepare the breasts for nursing.
- D. condition the pregnant woman for the 'work' of childbirth.
Correct Answer: B
Rationale: Kegel exercises strengthen pelvic floor muscles, supporting bladder control and aiding postpartum recovery, directly addressing their purpose.
The licensed practical nurse (LPN) assigns the ambulation of a client to unlicensed assistive personnel (UAP). The LPN observes UAP placing the clients Foley bag on the IV pole at the level of the client's chest during client ambulation down the length of the hallway. What action should the LPN take initially?
- A. Immediately lower the bag and speak privately to unlicensed assistive personnel (UAP)
- B. Let UAP complete assigned tasks and speak to them at the end of the shift
- C. Praise UAP for encouraging the client to walk the entire hallway
- D. Speak with the nurse manager about the need for UAP inservice education
Correct Answer: A
Rationale: The Foley bag must be kept below bladder level to prevent urine backflow and infection risk. Immediate correction and private education ensure safety and learning without delay.
The nurse is caring for assigned clients. Which of the following clients is at highest risk for developing delirium?
- A. 32-year-old client with gastroenteritis, dehydration, and a low-grade fever
- B. 55-year-old client with coronary artery disease who had coronary artery bypass surgery four days ago
- C. 60-year-old client with type 2 diabetes mellitus who had bilateral above-the-knee amputations two months ago
- D. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis
Correct Answer: D
Rationale: The 80-year-old with COPD, respiratory failure, and urosepsis has multiple delirium risk factors: advanced age, infection, and chronic illness. Younger clients with less severe conditions have lower risk.