Nokea
The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first?
- A. Weight reduction
- B. Stress management
- C. Physical exercise
- D. Smoking cessation
Correct Answer: D
Rationale: Smoking cessation. Stopping smoking is the priority for clients at risk for cardiac disease, because of its effects of reducing oxygenation and constricting blood vessels.
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A nurse in the pediatric unit is preparing a 16-year-old for a surgical procedure and observes that the client has signed the informed consent for surgery. What should be the first action by the nurse?
- A. Cancel the procedure until a valid consent form is signed
- B. Determine if the client meets legal requirements to sign the consent form
- C. Locate the client's parent or guardian to sign the consent form
- D. Verify that the consent is properly witnessed and send the client to surgery
Correct Answer: B
Rationale: Minors typically cannot provide legal consent unless they are emancipated or meet specific legal criteria. The nurse must first determine if the 16-year-old is legally able to sign the consent.
A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client?
- A. Moist mucous membranes
- B. Urinary frequency
- C. Poor skin turgor
- D. Increased blood pressure
Correct Answer: C
Rationale: Poor skin turgor. The specific gravity value is high, indicating dehydration. Poor skin turgor (tenting of the skin) is consistent with this problem.
The nurse has attended a staff education program about needlestick injuries. Which of the following statements by the nurse would require follow-up?
- A. Needlestick injuries should be reported to the employee health clinic.
- B. Needlestick injuries can be prevented by recapping needles after use.
- C. Postexposure prophylaxis may be prescribed after a needlestick injury occurs.
- D. Soap and water should be used to wash the affected area after a needlestick injury occurs.
Correct Answer: B
Rationale: Recapping needles increases the risk of injury and is not recommended. Needles should be disposed of in sharps containers immediately after use.
Laboratory results
Glucose (random)
71-200 mg/dL
(3.9–11.1 mmol/L) 58 mg/dL
(3.2 mmol/L)
The nurse is caring for a client with type 2 diabetes mellitus who reports feeling lightheaded and shaky. Which of the following actions should the nurse take next?
- A. Administer glucagon by subcutaneous injection as prescribed
- B. Administer rapid-acting insulin per sliding scale as prescribed
- C. Give the client 4 oz (120 mL) of fruit juice or a regular soft drink
- D. Give the client a snack of cheese or peanut butter with crackers
Correct Answer: C
Rationale: Lightheadedness and shakiness suggest hypoglycemia. Providing 15 grams of fast-acting carbohydrates, such as 4 oz of fruit juice, is the first-line treatment to raise blood glucose levels quickly.
Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students?
- A. Scratching the head more than usual
- B. Flakes evident on a student's shoulders
- C. Oval pattern occipital hair loss
- D. Whitish oval specks sticking to the hair
Correct Answer: D
Rationale: Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment can include application of a medicated shampoo with lindane for children over 2 years of age, and meticulous combing and removal of all nits.