Nokea
The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse perform first?
- A. Explain that the procedure will help him to get well
- B. Show a cartoon character with a blood pressure cuff
- C. Explain that the blood pressure checks the heart pump
- D. Permit handling the equipment before putting the cuff in place
Correct Answer: D
Rationale: Permit handling the equipment before putting the cuff in place. The best way to gain the toddler's cooperation is to encourage handling the equipment. Detailed explanations are not helpful.
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Before administering a feeding through a gastrostomy tube, what is the priority nursing assessment?
- A. Measure the vital signs
- B. Palpate the abdomen
- C. Assess for breath sounds
- D. Verify tube patency
Correct Answer: D
Rationale: Tube patency should be checked prior to all feedings. The feeding should not be attempted if the tube is not patent.
The nurse is caring for a client diagnosed with a deep venous thrombosis 1 day ago. Which action by the client would require an immediate intervention by the nurse?
- A. Ambulates through the hallway several times per day
- B. Applies a warm compress to the site of inflammation
- C. Elevates the limb above the level of the heart while in bed
- D. Massages the affected leg to reduce pain and swelling
Correct Answer: D
Rationale: Massaging the leg (D) risks dislodging the clot, causing embolism, requiring immediate intervention. Ambulation (A), warm compresses (B), and elevation (C) are appropriate.
The nurse is caring for a client with heart failure who develops a persistent, dry cough after starting enalapril. Which of the following new prescriptions would the nurse anticipate for this client?
- A. Alprazolam
- B. Guaifenesin
- C. Lisinopril
- D. Valsartan
Correct Answer: D
Rationale: A dry cough is a common side effect of ACE inhibitors like enalapril, so switching to an ARB like valsartan (D) is anticipated. Alprazolam (A), guaifenesin (B), and lisinopril (C, another ACE inhibitor) are inappropriate.
Before giving furosemide (Lasix) to an adult, the nurse checks the laboratory report for the last serum potassium level. Which finding would be of concern to the nurse?
- A. 3.2 mEq/L
- B. 3.7 mEq/L
- C. 4.1 mEq/L
- D. 4.9 mEq/L
Correct Answer: A
Rationale: A potassium level of 3.2 mEq/L is low, concerning with furosemide, which can further deplete potassium, risking arrhythmias.
A 31-year-old client is admitted to the psychiatric unit after cutting both wrists with a kitchen knife. The client has a diagnosis of borderline personality disorder. The most therapeutic approach by the nurse is one that is:
- A. Warm and nurturing
- B. Open and flexible
- C. Firm and consistent
- D. Nonintrusive and passive
Correct Answer: C
Rationale: A firm and consistent approach provides structure and boundaries, which are therapeutic for clients with borderline personality disorder who often test limits.