Nokea
The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated
- A. I can only wear cotton socks.'
- B. I cannot go barefoot around my house.'
- C. I will trim corns and calluses regularly.'
- D. I should ask a family member to inspect my feet daily.'
Correct Answer: C
Rationale: I will trim corns and calluses regularly.' Clients who are elderly, have diabetes, and/or have vascular disease often have decreased circulation and sensation in one or both feet. Their vision may also be impaired. Therefore, they need to be taught to examine their feet daily or have someone else do so. They should wear cotton socks which have not been mended, and always wear shoes when out of bed. They should not cut their nails, corns, and calluses, but should have them trimmed by their provider, nurse, or another provider who specializes in foot care.
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The nurse is caring for a client who is receiving intravenous fluid therapy. Which observation needs to be reported to the charge nurse?
- A. The client says the IV fluid feels cool when it goes in.
- B. The infusion site is covered with clear tape.
- C. The client is ambulating while the IV infusion is running.
- D. The area around the infusion site is cool and blanched.
Correct Answer: D
Rationale: A cool, blanched infusion site suggests infiltration or extravasation, requiring immediate reporting to prevent tissue damage. Cool fluid sensation, tape, or ambulation are normal.
A 75-year-old man following a right total hip replacement. The nurse's notes indicate that since the surgery the patient has become disoriented and confused at night. One evening as the nurse prepares the patient for sleep, the patient glances to his left and says, 'Oh, you think so?' and starts to laugh.
Which of the following responses by the nurse is the BEST?
- A. Do you hear voices talking to you?'
- B. Tell me why you are laughing so I can laugh too.'
- C. What is it that you find amusing?'
- D. I notice you're laughing.'
Correct Answer: D
Rationale: Strategy: Remember therapeutic communication. (1) yes/no question, may make client defensive and block communication (2) feeds into client's altered-reality state, nurse should suspect a hallucination (3) confrontation would block communication (4) correct-therapeutic statement of client's nonverbal communication
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin glargine (Lantus) 20 units subcutaneously at bedtime. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 100 mg/dL.
- B. Heart rate of 80 bpm.
- C. Sweating and irritability.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: C
Rationale: Sweating and irritability indicate hypoglycemia, a serious complication of insulin glargine, requiring immediate treatment with carbohydrates. Options A, B, and D are normal: glucose 100 mg/dL, heart rate 80 bpm, and blood pressure 120/80 mmHg indicate stability.
The nurse is teaching a client with a new diagnosis of chronic obstructive pulmonary disease (COPD) about tiotropium (Spiriva). Which of the following instructions should the nurse include?
- A. Use the inhaler as needed for shortness of breath.
- B. Report any eye pain or vision changes.
- C. Stop the medication if symptoms improve.
- D. Avoid rinsing the mouth after use.
Correct Answer: B
Rationale: Eye pain or vision changes may indicate glaucoma, a serious tiotropium side effect. Options A, C, and D are incorrect.
A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack?
- A. Cheese crackers
- B. Peanut butter sandwich
- C. Potato chips
- D. Vanilla cookies
Correct Answer: C
Rationale: Children with celiac disease should eat a gluten free diet. Potato chips are naturally gluten-free, unlike the other options which contain wheat-based ingredients.