Nokea
The nurse is providing postoperative teaching to a client on ways to prevent constipation. Which information should the nurse include?
- A. Drink 800 to 1,000 milliliters of fluid daily.
- B. Take oxycodone as scheduled to prevent painful bowel movements.
- C. Add fat-containing foods in the diet to lubricate stools for easier passage.
- D. Ambulate early and as frequently as possible.
Correct Answer: D
Rationale: Ambulation stimulates bowel function.
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The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?
- A. Print the electronic medical record (EMR) from a backup server.
- B. Identify information as a late entry in the record.
- C. Wait for notification that the system has been rebooted.
- D. Notify the information services department of the situation.
Correct Answer: D
Rationale: Notifying IT resolves system issues promptly.
The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?
- A. Dizziness can occur during cleansing.
- B. The pubic area should be kept shaved.
- C. The foreskin should not be retracted.
- D. An erection may occur while providing care.
Correct Answer: D
Rationale: Reflex erection is normal and should be explained.
The nurse retrieves hydromorphone '4 mg/mL' from the electronic medication system, for a patient who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the nurse administer to the patient? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 0.8
Rationale: 3 mg ÷ 4 mg/mL = 0.75 mL, rounded to 0.8 mL.
A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?
- A. Document the site where the medication was given.
- B. Notify the healthcare provider of the allergic response.
- C. Elevate the area and apply light pressure over the site.
- D. Apply a cold pack to the area for twenty minutes.
Correct Answer: A
Rationale: Wheal is normal and should be documented.
A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement?
- A. Orient the client to their surroundings.
- B. Close the client's room door.
- C. Escort the client back to the room.
- D. Raise the four side rails on the bed.
- E. Secure a bed alarm on the mattress.
Correct Answer: A,C,E
Rationale: Orientation, escort, and alarm ensure safety.