Nokea
The nurse is presenting a home safety class on carbon monoxide toxicity to a group of older adults. Which statement would be appropriate for the nurse to make to the group of clients?
- A. Carbon monoxide is a gas that is gray in color and deadly.
- B. Carbon monoxide is a clear and odorless gas.
- C. Early signs of carbon monoxide toxicity include nose bleed and tremors.
- D. Carbon monoxide is a gas that smells like rotten eggs.
Correct Answer: B
Rationale: Carbon monoxide is a colorless, odorless gas, making detectors essential. It is not gray, does not smell like rotten eggs, and early signs include headache, not nosebleeds or tremors.
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The nurse is preparing to administer a low-cleansing enema to a client. Which action by the nurse is appropriate during the administration of the enema?
- A. Administer the enema with the client in a supine position.
- B. Insert the enema tube 2 inches into the rectum.
- C. Use cold tap water for the enema solution.
- D. Hang the enema bag approximately 12 inches above the client's rectum.
Correct Answer: D
Rationale: Hanging the bag 12 inches above the rectum ensures proper flow. Supine position is incorrect, insertion is 3-4 inches, and cold water causes cramping.
The first bodily area to be washed during a complete bed bath is the:
- A. Inner canthus of the eye
- B. Cheeks
- C. Forehead
- D. Chin
Correct Answer: A
Rationale: Washing from the inner canthus of the eye outward prevents debris spread and is the starting point for a bed bath. Other areas follow.
The nurse is teaching a client about a vegetarian diet. Which of the following foods should the nurse recommend for this diet? Select all that apply.
- A. Legumes
- B. Almond butter
- C. Grilled chicken
- D. Apricots
- E. Baked fish
- F. Seafood salad
Correct Answer: A,B,D
Rationale: Vegetarian diets exclude meat, so legumes, almond butter, and apricots are suitable. Chicken, fish, and seafood are not vegetarian.
The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
- A. Discomfort while speaking
- B. Frequent swallowing
- C. Drowsiness
- D. Pain with occasional coughing
Correct Answer: B
Rationale: Frequent swallowing in a post-tonsillectomy child may indicate bleeding in the throat, as the child swallows blood, requiring immediate follow-up to prevent hemorrhage. Discomfort, drowsiness, and pain with coughing are expected findings and less urgent.
The nurse supervises unlicensed assistive personnel (UAP) assist a bed-bound client with oral hygiene. Which action by the UAP requires follow-up? Select all that apply.
- A. Raises the head of the bed (HOB) to 15 degrees
- B. Positions the toothbrush bristles at a 45-degree angle to the gum line
- C. A pulse of 5 is abnormally low for a 5-year-old (normal 70-120). BP 110/60, RR 24, and temperature 37°C are within normal limits. None Regular The correct answer is A. Rationale: Pulse 5 is bradycardic for a child.
- D. Removes the towel and places it in a biohazard bag
- E. Applies moisturizing lubricant to the lips after brushing and rinsing
Correct Answer: A,D
Rationale: These actions by the UAP require follow-up. The head of the bed should ideally be elevated to between 30-45 degrees to facilitate effective oral hygiene and reduce the risk of aspiration. A lower angle may make it more difficult for the client to swallow properly and increase the risk of choking. Placing a towel used for oral hygiene in a biohazard bag is unnecessary unless it is saturated with blood or other potentially infectious materials. The towel used to protect the client's clothing during oral hygiene is typically considered regular linen and should be placed in a linen bag for laundering. Using a biohazard bag for non-contaminated items increases waste and may lead to confusion in waste management procedures.