Nokea
The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about home oxygen therapy. Which of the following instructions should the nurse include?
- A. Use oxygen only when feeling short of breath.
- B. Store oxygen tanks near an open flame.
- C. Avoid smoking while using oxygen.
- D. Use a humidifier with oxygen at high flow rates.
Correct Answer: C
Rationale: Smoking near oxygen risks fire, a critical safety concern. Options A, B, and D are incorrect or unsafe.
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The nurse is preparing a client for a magnetic resonance imaging (MRI). Which of the following client statements indicates to the nurse that teaching has been successful?
- A. The dye used in the Test will turn my urine green for about 24 hours.'
- B. I will be put to sleep for this procedure. I will return to my room in two hours.'
- C. This procedure will take about 90 minutes to complete. There will be no discomfort.'
- D. The wires that will be attached to my head and chest will not cause me any pain.'
Correct Answer: C
Rationale: procedure takes approximately 90 minutes, not painful
A teenager comes to the clinic complaining of fatigue, a sore throat, and flu-like symptoms for the previous two weeks. Physical exam reveals enlarged lymph nodes and temperature of 100.3°F (37.9°C). Which of the following statements by the nurse is BEST?
- A. Cover your mouth and nose when you sneeze or cough.
- B. Eat in a separate room away from your family.
- C. Don't share your drinking glass or silverware with anybody.
- D. Stay in your room until all of your symptoms are gone.
Correct Answer: C
Rationale: symptoms indicate mononucleosis, spread by direct contact; advise family to avoid contact with cups and silverware for about 3 months
The nurse is caring for a client with a history of seizures. The client begins to experience a tonic-clonic seizure. Which of the following actions should the nurse take FIRST?
- A. Restrain the client to prevent injury.
- B. Place a tongue depressor in the client's mouth.
- C. Turn the client to the side.
- D. Administer lorazepam (Ativan) IV.
Correct Answer: C
Rationale: turning the client to the side helps maintain a patent airway and prevents aspiration during a seizure
The nurse is caring for a client with a diagnosis of schizophrenia. Which of the following statements is MOST descriptive of the affect of a patient with schizophrenia?
- A. The client answers all questions with one word.
- B. The client laughs while talking about being raped.
- C. The client exhibits no energy or interest in tasks.
- D. The client cries while talking about mother's death.
Correct Answer: B
Rationale: inappropriate affect, expression of feelings bizarre for situation
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body?
- A. Counseling regarding problems of body image.
- B. Maintain airborne precautions.
- C. Maintain aseptic technique during procedures.
- D. Encourage peers to visit on a regular basis.
Correct Answer: C
Rationale: A teenager with 50% body burns is at high risk for infection due to loss of skin barrier. Maintaining aseptic technique during procedures is the highest priority to prevent life-threatening infections. Counseling, precautions, and peer visits are important but secondary to infection control.