Nokea
The nurse is providing discharge teaching to a client with a new colostomy. Which statement by the client indicates a need for further teaching?
- A. I will avoid foods that cause gas.
- B. I will change my colostomy bag every week.
- C. I will use a skin barrier to protect the skin around the stoma.
- D. I will empty my colostomy bag when it is one-third full.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A public health nurse is planning a campaign to increase immunization rates among children in a low-income community. Which intervention should the nurse prioritize?
- A. provide free immunizations at local schools
- B. create educational materials about vaccine safety
- C. organize a community forum to discuss immunization concerns
- D. partner with local media to promote the importance of vaccines
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assessing a client with pneumonia who is receiving oxygen therapy. Which finding indicates that the therapy is effective?
- A. The client's respiratory rate is 20 breaths per minute.
- B. The client's arterial blood gases show a pH of 7.35.
- C. The client's oxygen saturation is 92%.
- D. The client's breath sounds are clear.
Correct Answer: A
Rationale: A respiratory rate of 20 breaths per minute indicates effective oxygen therapy. In pneumonia, the respiratory rate typically increases due to the body's effort to improve oxygenation. Option B (pH of 7.35) is related to acid-base balance, not specifically indicating oxygen therapy effectiveness. Option C (oxygen saturation of 92%) is below the normal range (95-100%), suggesting the need for oxygen therapy. Option D (clear breath sounds) is a positive finding but not a direct indicator of oxygen therapy effectiveness.
A female client is admitted with a tentative diagnosis of Guillain-Barre syndrome. Which finding is most important for the nurse to report to the healthcare provider?
- A. Facial weakness and difficulty speaking.
- B. Decreased deep tendon reflexes in the legs.
- C. Inability to move the eyes.
- D. Respiratory distress and cyanosis.
Correct Answer: B
Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.
A female client reports to the nurse that her sleep was interrupted by 'thoughts of anger towards my husband.' What type of thoughts is the client having?
- A. Obsessive.
- B. Phobic.
- C. Delusional.
- D. Paranoid.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a history of diabetes mellitus is admitted with hypoglycemia. Which finding requires immediate intervention?
- A. Blood glucose of 60 mg/dL.
- B. Heart rate of 100 beats per minute.
- C. Tremors.
- D. Diaphoresis.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.