Nokea
The nurse is working on a plan to assist an abused client back into the work situation. Which will likely be most helpful in decreasing the trauma for the client?
- A. Support from significant others
- B. Support from a counselor
- C. Support from friends
- D. Support from coworkers
Correct Answer: A
Rationale: Support from significant others provides emotional stability, most effective in reducing trauma for an abused client re-entering work.
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The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client should be assigned to the nursing assistant?
- A. A client with laparoscopic cholecystectomy
- B. A client with viral pneumonia
- C. A client with suspected ectopic pregnancy
- D. A client with intermittent chest pain
Correct Answer: B
Rationale: A nursing assistant can provide basic care such as hygiene and vital signs for stable clients. A client with viral pneumonia, if stable, requires less complex care compared to post-surgical , potential emergency , or cardiac clients, which require licensed staff.
A client has orders for cefoxitin (Mefoxin) 2 g IV piggyback in 100 cc 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity.
It is MOST important for the nurse to take which of the following actions?
- A. Administer the medication slowly, at 25-25 cc/h.
- B. Change the primary IV solution.
- C. Hang the piggyback infusion bag higher than the primary infusion bag.
- D. Obtain an infusion pump prior to administration.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) antibiotic should be administered within one hour (2) unnecessary for safe infusion (3) correct-when using a gravity drip, piggyback fluid level needs to be higher than primary infusion (4) unnecessary for safe infusion
An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture.
- A. What is the most important nursing care plan inclusion for an elderly client post-femoral fracture repair?
- B. Eat a high-protein, low-residue diet.
- C. Lie on her unoperated side.
- D. Exercise her arms and legs.
- E. Cough and deep breathe.
Correct Answer: D
Rationale: Coughing and deep breathing prevent respiratory complications like pneumonia, a significant risk due to immobility post-surgery. A high-residue diet prevents constipation, positioning varies, and exercises are secondary to respiratory care.
The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is an appropriate finger food?
- A. Hot dog pieces
- B. Sliced bananas
- C. Whole grapes
- D. Popcorn
Correct Answer: B
Rationale: Sliced bananas. Finger foods should be bite-size pieces of soft food such as bananas. Hot dogs and grapes can accidentally be swallowed whole and-mile occlude the airway. Popcorn is too difficult to chew at this age and can irritate the airway if swallowed.
A client is scheduled for electromyography (EMG).
What should the nurse tell the client about the procedure?
- A. Your hair will be carefully washed prior to the procedure.'
- B. This is a noninvasive procedure that takes about 30 minutes.'
- C. A sedative will be given to you shortly before the procedure.'
- D. You will not be allowed to eat 4-6 hours before the procedure.'
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) usually performed on the legs (2) correct-electrodes are attached to legs, length of time for impulse transmission is measured (3) may impair Test results (4) doesn't involve general anesthesia or GI system