Nokea
The nurse is reinforcing teaching to a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply.
- A. Avoid excess caffeine
- B. Immerse hands in cold water
- C. Practice yoga or tai chi
- D. Refrain from using tobacco products
- E. Wear gloves when handling cold objects
Correct Answer: A,C,D,E
Rationale: Caffeine, tobacco, and cold exposure can trigger Raynaud episodes. Yoga/tai chi and gloves help prevent attacks. Cold water immersion exacerbates symptoms.
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The daughter of an 80-year-old client recently diagnosed with Alzheimer disease (AD) says to the nurse, 'I guess I can anticipate getting this disease myself at some point.' What is an appropriate response by the nurse?
- A. Engaging in regular exercise decreases the risk of AD.
- B. Having a family history of AD is not a risk factor.
- C. Try not to worry about this now as you can't do anything to prevent AD.
- D. You should avoid aluminum cans and cookware to prevent AD.
Correct Answer: A
Rationale: Regular exercise is associated with a reduced risk of Alzheimer disease. Family history is a risk factor, and aluminum is not a proven cause.
The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should
- A. Review the medications the client is receiving
- B. Increase the formula infusion rate
- C. Increase the amount of water used to flush the tube
- D. Attach a rectal bag to protect the skin
Correct Answer: A
Rationale: Review the medications the client is receiving. Medications like antibiotics can cause diarrhea, requiring evaluation.
The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next?
- A. Check for a carotid pulse for at least 10 seconds
- B. Provide rescue breaths at a rate of 10-12/min
- C. Resume chest compressions at a rate of 100/min
- D. Use the jaw-thrust maneuver to assess the airway
Correct Answer: C
Rationale: If no shock is advised, CPR should resume immediately with chest compressions to restore circulation.
The best choice for the child following a tonsillectomy is:
- A. Fruit punch
- B. Grape soda
- C. A banana Popsicle
- D. Ice cream
Correct Answer: C
Rationale: A banana Popsicle is soothing, cold, and non-irritating to the surgical site. Liquids like punch or soda may sting, and ice cream is dairy, which can increase mucus.
The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply.
- A. I should rinse my mouth with water before collecting the sputum.
- B. I will be careful not to touch the inside of the specimen cup or lid.
- C. I will inhale deeply a few times and then cough forcefully.
- D. It is best to collect the sputum mid-day when my secretions are loose.
- E. It is helpful if I am sitting upright when I collect the sputum.
Correct Answer: A,B,C,E
Rationale: Rinsing the mouth, avoiding contamination, deep coughing, and sitting upright ensure a quality specimen. Morning collection is preferred for higher yield.