Nokea
The nurse is to move a client up in bed without any help. Where should the nurse place the client's pillow?
- A. At the bottom of the bed
- B. On the bedside stand
- C. At the head of the bed
- D. Under the client's head
Correct Answer: C
Rationale: Placing the pillow at the head of the bed supports the client's head after moving up, ensuring comfort and proper positioning.
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A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss?
- A. The newborn needs additional assessments
- B. The mother should breast feed more often
- C. A change to formula is indicated
- D. The loss is within normal limits
Correct Answer: D
Rationale: The loss is within normal limits. A newborn is expected to lose 5-10% of the birth weight in the first few days post-partum because of changes in elimination and feeding.
A 70-year-old man with a history of hypertension and closed-angle glaucoma visits the clinic for a routine check-up. Which of the following medications, if ordered by the physician, should the nurse question?
- A. Propranolol (Inderal), 80 mg PO QID.
- B. Verapamil (Nifedipine), 40 mg PO TID.
- C. Tetrahydrozoline (Visine), 2 gtts OU TID.
- D. Timolol (Timoptic solution), 1 gtt OU QD.
Correct Answer: C
Rationale: contraindicated; ophthalmic vasoconstrictor, contraindicated with closed angle glaucoma; use cautiously with hypertension
A client hospitalized with bipolar disorder, manic phase, begins to talk loudly, pace the floor, and shout commands to others in the day room as he quickly changes the TV channels. The nurse's first action should include:
- A. Checking the client's medication order
- B. Escorting the client from the day room
- C. Placing the client in seclusion
- D. Finding out whether the client's behavior is upsetting others in the day room
Correct Answer: B
Rationale: Escorting the client from the day room de-escalates the situation by removing them from a stimulating environment, reducing agitation.
An adult has completed an alcohol detoxification program and is being discharged with disulfiram (Antabuse). Which statement that the client makes indicates a need for more teaching?
- A. I have learned my lesson. I won't drink more than two beers.'
- B. I will not use mouthwash while I am taking Antabuse.'
- C. I should take the Antabuse every day.'
- D. If I have to go to the emergency room for any reason, I will tell them I take Antabuse.'
Correct Answer: A
Rationale: Planning to drink alcohol (even minimally) while on disulfiram indicates misunderstanding, as it causes severe reactions with alcohol. Other statements show proper understanding.
A client arrives in the emergency department after a radiologic accident at a local factory. The first action of the nurse would be to
- A. begin decontamination procedures for the client
- B. ensure physiologic stability of the client
- C. wrap the client in blankets to minimize staff contamination
- D. double bag the client's contaminated clothing
Correct Answer: B
Rationale: The nurse must initially assist in stabilizing the patient prior to performing the other tasks related to radiologic contamination.