Nokea
The nurse is preparing to assist a client to ambulate to the bathroom. The client rises from the chair at the bedside and immediately reports feeling dizzy. It would be a priority for the nurse to
- A. Check the client's orthostatic blood pressure
- B. encourage the client to remain on bed rest
- C. apply a gait belt around the client's waist
- D. assist the client back to a sitting position
Correct Answer: D
Rationale: Dizziness upon standing suggests orthostatic hypotension or other instability. Assisting the client back to a sitting position prevents falls and ensures immediate safety.
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The nurse is reinforcing teaching with an adolescent client who has acne vulgaris. Which of the following information should the nurse reinforce? Select all that apply.
- A. A well-balanced diet can help support healthy skin.
- B. Antibacterial soap is harsh and can make your acne worse.
- C. Scrub whiteheads vigorously when washing your face twice daily.
- D. Squeezing or picking the lesions may increase the risk for infection and scarring.
- E. Use skin care products labeled as noncomedogenic to avoid clogging your skin pores.
Correct Answer: A,B,D,E
Rationale: A balanced diet (A), avoiding harsh soaps (B), not picking lesions (D), and using noncomedogenic products (E) promote skin health and prevent acne exacerbation.
An adult who has hepatitis A asks the nurse why her skin is yellow. The nurse should include which information when replying?
- A. The diseased liver is not able to convert bilirubin into bile, so bilirubin pigments stay in the bloodstream and cause the skin and sclera to turn yellow.
- B. The virus that causes hepatitis A leaves a yellow pigment in the bloodstream.
- C. The affected liver cells produce more bilirubin than usual, causing the skin to turn yellow.
- D. The body is trying to get rid of fecal waste products through the skin.
Correct Answer: A
Rationale: Hepatitis A impairs liver function, reducing bilirubin conjugation and excretion, leading to its accumulation in the blood, causing jaundice. The virus does not produce pigment, nor does the liver overproduce bilirubin or excrete waste through skin.
A nurse is admitting a client at 42 weeks gestation to the labor and delivery unit for induction of labor. What is a predictor of a successful induction?
- A. Bishop score of 10
- B. Firm and posterior cervix
- C. History of precipitous labor
- D. Reactive nonstress test
Correct Answer: A
Rationale: A Bishop score of 10 indicates a favorable cervix (soft, dilated, effaced, anterior), predicting a higher likelihood of successful induction.
The home health nurse is caring for a 6-year-old client who has a tracheostomy and is being mechanically ventilated when the ventilator's apnea alarm sounds. The nurse determines the client is unresponsive and pulseless, and there are no other caregivers present. Which of the following actions should the nurse take next?
- A. Deliver 30 chest compressions.
- B. Activate the emergency response system.
- C. Locate an automated external defibrillator.
- D. Deliver 2 breaths using a bag valve device connected to the tracheostomy.
Correct Answer: B
Rationale: Activating the emergency response system ensures rapid assistance for a pulseless child, initiating the chain of survival in pediatric cardiac arrest.
A student nurse is caring for a client with iron deficiency anemia who is newly prescribed ferrous sulfate. Which action by the student nurse requires the supervising nurse to intervene?
- A. Encourages the client to drink extra fluids while taking ferrous sulfate
- B. Offers the client orange juice for administration of ferrous sulfate
- C. Plans to administer ferrous sulfate one hour before breakfast
- D. Prepares to administer a prescribed calcium supplement with ferrous sulfate
Correct Answer: D
Rationale: Calcium inhibits iron absorption, so administering ferrous sulfate with a calcium supplement reduces its effectiveness, requiring intervention.