Nokea
The nurse is preparing to pull a thin, frail client up in the bed. No one responds to the nurse's call for lifting assistance. Which is the best action by the nurse?
- A. call again and apologize to the client for the wait
- B. stand behind the bed at the client's head, and pull her up gently from her armpits
- C. since the client is small, pull her up in the bed by pulling on the draw sheet, alternating sides
- D. if the client is able to roll and bend her knees, lower the head of the bed and place it in Trendelenburg's position while helping the client bend her knees and push up
Correct Answer: C
Rationale: Using the draw sheet to pull the client up is the safest option to prevent injury to both the client and nurse when assistance is unavailable.
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A client has orders for placing a small-bore nasoenteric tube. Which finding in the health history would prompt the nurse to notify the prescriber before placing tube?
- A. small-bowel lesion
- B. basilar skull fracture
- C. acute coronary syndrome
- D. use of diabetic insulin pump
Correct Answer: B
Rationale: A basilar skull fracture is a contraindication for nasoenteric tube placement due to the risk of intracranial insertion. Other conditions are not absolute contraindications.
A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid:
- A. Calcium-rich foods
- B. Canned or frozen vegetables
- C. Processed meat
- D. Raw fruits and vegetables
Correct Answer: D
Rationale: Raw fruits and vegetables may harbor pathogens, increasing infection risk in immunocompromised clients with HIV.
The nurse is teaching the mother of a child with attention deficit disorder regarding the use of Ritalin (methylphenidate). The nurse recognizes that the mother understands her teaching when she states the importance of:
- A. Offering high-calorie snacks
- B. Watching for signs of infection
- C. Observing for signs of oversedation
- D. Using a sunscreen with an SPF of 30
Correct Answer: C
Rationale: Ritalin, a stimulant, can cause side effects like insomnia or agitation, not oversedation. The mother's mention of oversedation indicates a misunderstanding, but the question implies correct teaching, so observing for side effects like overstimulation is key.
An adolescent client with cystic acne has a prescription for Accutane (isotretinoin). Which lab work is needed before beginning the medication?
- A. Complete blood count
- B. Clean-catch urinalysis
- C. Liver profile
- D. Thyroid function test
Correct Answer: C
Rationale: A liver profile is required before starting isotretinoin due to its potential hepatotoxicity, ensuring safe administration.
The nurse is preparing to administer a dose of amoxicillin (Amoxil) to a client with a urinary tract infection. The client reports a history of penicillin allergy. Which of the following actions should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Administer half the dose and monitor for reactions.
- D. Ask the client about the type of allergic reaction.
Correct Answer: D
Rationale: clarifying the type of allergic reaction is essential, as amoxicillin is a penicillin derivative and could cause a severe reaction