Nokea
The nurse is talking with a client who is scheduled for a lumbar puncture. Which of the following statements by the client would require follow-up?
- A. I will need to lie on my stomach during the procedure.
- B. I should go to the bathroom to urinate before the procedure.
- C. I understand that a needle will be inserted between the bones in my lower spine during the procedure.
- D. I may experience a sharp pain radiating down my leg during the procedure, but it should pass quickly.
Correct Answer: A
Rationale: Lumbar punctures are typically performed in a lateral or sitting position, not prone (A), requiring clarification. Urinating beforehand (B), needle insertion (C), and transient pain (D) are correct.
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An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client's confusion by:
- A. Assigning a nursing assistant to sit with him until he falls asleep
- B. Allowing the client to room with another elderly client
- C. Administering a bedtime sedative
- D. Leaving a night light on during the evening and night shifts
Correct Answer: D
Rationale: A night light reduces confusion by improving visibility and orientation. Constant supervision is impractical, room-sharing may worsen confusion, and sedatives increase fall risk.
A client with insulin-dependent diabetes takes 20 units NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:
- A. 8 a.m.
- B. 10 a.m.
- C. 3 p.m.
- D. 5 a.m.
Correct Answer: C
Rationale: NPH insulin peaks 6-12 hours after administration (1-3 p.m.), making 3 p.m. the time to watch for hypoglycemia. Other times are outside the peak window.
The nurse has delegated the task of taking the temperature of a client with a new tympanic thermometer to a certified nursing assistant. The nursing assistant says, 'This looks easy. I am good at figuring things out.' What is the nurse's responsibility?
- A. Allow the nursing assistant to proceed.
- B. Assign the task to another nursing assistant.
- C. Ask another nursing assistant to demonstrate this task to the nursing assistant.
- D. Demonstrate the proper use of the thermometer and observe the nursing assistant.
Correct Answer: D
Rationale: Demonstrating and observing ensures the CNA uses the tympanic thermometer correctly, maintaining accuracy and safety.
The clinic nurse is planning to assess the visual acuity of a 6-year-old. Which method is the best way to assess visual acuity in this child?
- A. Have the child identify different objects using Allen figure testing cards
- B. Have the child point in the direction each letter is facing on a tumbling E chart
- C. Have the child read letters on a Snellen chart while standing 10 ft (3 m) away
- D. Have the child view a set of Ishihara colored cards one at a time
Correct Answer: B
Rationale: The tumbling E chart (B) is age-appropriate for a 6-year-old, who may not know letters. Allen cards (A) are for younger children, Snellen at 10 ft (C) is non-standard, and Ishihara (D) tests color vision.
The nurse is reviewing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan?
- A. Canned baby food is more expensive than food prepared at home
- B. Finger foods can be introduced before the child has teeth
- C. New foods should be introduced at least 5-7 days apart
- D. Rice cereal can be mixed with cow's milk to increase nutritional intake
Correct Answer: C
Rationale: Introducing new foods 5-7 days apart (C) prevents allergic reactions by identifying triggers, making it the priority. Cost (A), finger foods (B), and cow's milk (D, not recommended before 12 months) are secondary.