Nokea
The nurse is to make several home visits today. All of the visits are within a 5-mile radius. All of the following persons need to be seen. Which person should the nurse visit first?
- A. An older adult who has diabetes, peripheral vascular disease, and leg ulcers and needs hygienic care and wound care
- B. An adult who has multiple myeloma and needs her weekly injection of interferon
- C. A woman with multiple sclerosis who needs hygienic care
- D. An elderly woman who is recovering from a cerebrovascular accident and needs hygienic care and range-of-motion (ROM) exercises
Correct Answer: A
Rationale: Leg ulcers in a diabetic with peripheral vascular disease pose infection and healing risks, prioritizing wound care. Other needs are less urgent.
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A postoperative client has a nasogastric (NG) tube following bowel surgery. The orders read, 'acetaminophen 650 PRN for fever above 101°F.' The client has a temperature of 101.4°F. What is the most appropriate nursing action?
- A. Administer the acetaminophen by rectal suppository.
- B. Administer the acetaminophen by elixir through the NG tube and turn suction off for 30 minutes.
- C. Administer the acetaminophen by crushing two tablets, giving it through the NG tube, and turning suction off for 30 minutes.
- D. Call the physician and question the order.
Correct Answer: A
Rationale: A rectal suppository is appropriate with an NG tube on suction, ensuring fever treatment without risking medication loss.
When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to
- A. Avoid smoking near the client
- B. Turn off oxygen during meals
- C. Adjust the liter flow to 10 as needed
- D. Remind the client to keep mouth closed
Correct Answer: A
Rationale: Avoid smoking near the client. Oxygen supports combustion, posing a fire risk if smoking occurs nearby.
A ten-year-old child with leukemia has a large burn on her arm and the burn appears to be oily. The client states that she touched a hot pan, and her mother put cooking fat on it so it would not blister.
The nurse should
- A. document the findings in the chart.
- B. call the physician immediately to report the injury.
- C. teach the client that oil holds germs and makes infection more likely.
- D. wash the burn with soap and water to remove the oil.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the immediate problem of cleansing the wound (2) unnecessary (3) does not address the immediate problem of cleansing the wound (4) correct-because leukemic clients are immunosuppressed, they are more susceptible to infections; cooking fat applied to an open wound increases the possibility of infection; burns should be rinsed immediately with tap water to reduce the heat in the burn
The nurse is teaching a client with a new diagnosis of glaucoma about timolol (Timoptic) eye drops. Which of the following instructions should the nurse include?
- A. Apply the drops in the morning.
- B. Report any shortness of breath.
- C. Use the drops every 4 hours.
- D. Avoid blinking after administration.
Correct Answer: B
Rationale: Timolol, a beta-blocker, can cause systemic effects like bronchospasm; shortness of breath requires reporting. Options A, C, and D are incorrect.
A 53-year-old who has pernicious anemia is being seen in the physician's office. Because the client has pernicious anemia, which comment is of greatest concern to the nurse?
- A. I have been having trouble reading the newspaper.'
- B. I have pain up and down my legs.'
- C. My knees hurt when I climb stairs.'
- D. I am so tired of having a headache.'
Correct Answer: B
Rationale: Leg pain suggests worsening neuropathy, a serious complication of pernicious anemia, requiring urgent evaluation to prevent irreversible nerve damage.