Nokea
The nurse is teaching a client with newly diagnosed diabetes mellitus about foot care. Which of the following instructions should the nurse include?
- A. Soak feet in hot water daily.
- B. Apply lotion between the toes.
- C. Trim toenails with rounded edges.
- D. Inspect feet daily for cuts or sores.
Correct Answer: D
Rationale: Daily foot inspection prevents complications like infections in diabetes. Options A, B, and C risk burns, fungal growth, or ingrown nails.
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A young woman who is at 32 weeks gestation reports to the physician's office for a routine prenatal visit. Which comment by the woman must be reported to the physician?
- A. I had to stop wearing my rings because my fingers are swollen.'
- B. I seem to be hotter than everyone else.'
- C. My feet tend to swell in the hot weather.'
- D. My breasts are so big and tender.'
Correct Answer: A
Rationale: Finger swelling severe enough to prevent wearing rings may indicate preeclampsia, requiring physician evaluation. Heat sensation, foot edema, and breast changes are normal in pregnancy.
After abdominal surgery, a client has a nasogastric tube attached to low suctioning.
- A. What is the most appropriate nursing intervention for a client with a nasogastric tube who becomes nauseated with decreased gastric secretion flow?
- B. Irrigate the nasogastric tube with distilled water.
- C. Aspirate the gastric contents with a syringe.
- D. Administer an antiemetic medicine.
- E. Insert a new nasogastric tube.
Correct Answer: B
Rationale: Nausea and decreased flow suggest possible NG tube obstruction. Aspirating gastric contents with a syringe confirms tube placement (pH 0-4) and checks for blockages, addressing the cause of symptoms. Irrigation should use normal saline after placement confirmation, and antiemetics or tube replacement do not assess tube function.
A client experiencing alcohol withdrawal.
Which finding would indicate to the nurse that a client experiencing alcohol withdrawal is in need of more sedation to control the severity of withdrawal symptoms?
- A. Increasing lethargy.
- B. Uncoordinated motor movements.
- C. Elevated pulse rate.
- D. Improved orientation to time and place.
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice and how it relates to alcohol withdrawal. (1) would indicate a need for less sedation and a thorough physical assessment (2) suggests neurological trauma or damage (3) correct-pulse rate is a good indicator of client's progress through withdrawal, increasingly elevated pulse signals impending alcohol withdrawal delirium, requiring more sedation (4) suggests that the client is improving and will subsequently require less sedation
If Ms. Barrett's distance vision is 20/30, which of the following statements is true?
- A. The client can read from 20' what a person with normal vision can read at 30'.
- B. The client can read from 30' what a person with normal vision can read at 20'.
- C. The client can read the entire chart from 30'.
- D. The client can read the chart from 20' with the left eye and from 30' with the right eye.
Correct Answer: A
Rationale: The numerator, which is always 20, is the distance in feet between the chart and the client. The denominator, which ranges from 10 to 200, indicates the distance at which a normal eye can read the chart.
The nurse is caring for a client with a history of heart failure who is receiving carvedilol (Coreg) 6.25 mg PO bid. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 90/60 mmHg.
- B. Heart rate of 70 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Oxygen saturation of 95%.
Correct Answer: A
Rationale: Hypotension (90/60 mmHg) is a serious carvedilol side effect, risking perfusion in heart failure. Options B, C, and D are normal.