Nokea
The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose?
- A. 1 mL
- B. 3 mL
- C. 10 mL
- D. 30 mL
Correct Answer: C
Rationale: A 10 mL syringe is recommended to avoid excessive pressure that could damage the catheter.
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The nurse is talking with a client whose spouse recently attempted suicide. The client states, 'If I had not intervened, my spouse would have died. I cannot believe this is happening.' Which of the following responses would be most appropriate for the nurse to make?
- A. Do not focus on the negative. You should try to focus on helping your spouse get better.
- B. I imagine that this is overwhelming. Tell me more about how you are feeling right now.
- C. Do you have any relatives or close friends who can help support you through this?
- D. Has your spouse been experiencing worsening depression recently?
Correct Answer: B
Rationale: Acknowledging the client's feelings and encouraging expression provides emotional support.
A nurse has been assigned to provide care to a client with suicidal ideation who is receiving treatment in an outpatient setting. The nurse develops a care plan and reviews it with the nurse preceptor before meeting with the client. Which proposed nursing action in the care plan requires intervention by the nurse preceptor?
- A. Assist the client in identifying the warning signs of a crisis
- B. Have the client write a list of people to contact for help and distraction
- C. Help the client develop ways of coping with suicidal thoughts
- D. Persuade the client to sign a contract promising not to attempt suicide
Correct Answer: D
Rationale: No-suicide contracts are not evidence-based and may create pressure rather than support coping strategies.
The nurse is talking with a client with acne vulgaris who has a new prescription for isotretinoin. Which of the following statements by the client would require follow-up?
- A. I will take an oral contraceptive and use condoms while taking isotretinoin.
- B. I need to wear sunscreen and sun-protective clothing while outdoors.
- C. I will take a vitamin A supplement daily while taking isotretinoin.
- D. I should avoid drinking alcohol while taking the medication.
Correct Answer: C
Rationale: Vitamin A supplements can increase the risk of toxicity with isotretinoin, which is a vitamin A derivative.
The nurse is talking with the parent of an adolescent client who arrived at the emergency department after discovering that the client was involved in a motor vehicle collision. The parent asks about the clients condition. The client is unconscious and is currently receiving CPR. Which of the following responses would be appropriate for the nurse to make?
- A. I do not have any information about your child's condition, but you can see your child now.
- B. Your child is critically ill, and we are currently caring for your child's needs.
- C. The health care team is currently attempting to revive your child after your child's heart stopped.
- D. Only the health care provider is allowed to discuss your child's condition with you.
Correct Answer: C
Rationale: Honest, clear communication about the critical situation (CPR) is appropriate while maintaining sensitivity.
Which of the following symptoms is associated with exacerbation of multiple sclerosis?
- A. Anorexia
- B. Seizures
- C. Diplopia
- D. Insomnia
Correct Answer: C
Rationale: Diplopia (double vision) is a common symptom during multiple sclerosis exacerbations, resulting from demyelination affecting the optic nerves or brainstem.