Nokea
The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?
- A. Lifting the affected leg with the palms of the hand
- B. Covering the affected leg with a blanket to avoid chills
- C. Placing plastic over the groin prior to bathing
- D. Elevating the cased leg on two pillows
Correct Answer: B
Rationale: The correct answer is covering the affected leg with a blanket to avoid chills. Covering the leg with a blanket can prevent the evaporation of heat from the new cast, which can lead to skin irritation or discomfort. Lifting the affected leg with the palms of the hand is appropriate as it helps in providing support and prevents unnecessary pressure on the cast. Placing plastic over the groin prior to bathing is also acceptable to protect the area from getting wet. Elevating the cased leg on two pillows helps reduce swelling and promotes circulation, making it a suitable action.
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After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention?
- A. Have the client take slow deep breaths in through their mouth and out through their nose.
- B. Post signs indicating that oxygen is in use on the client's door and in their room
- C. Apply Vaseline petroleum to both nares and 2 by 2 gauze around the oxygen tubing at the client's ears
- D. Encourage the client to hyperextend the neck, take a few deep breaths and cough.
Correct Answer: A
Rationale: After applying oxygen using bi-nasal prongs to a client with chest pain, it is essential for the nurse to post signs indicating that oxygen is in use on the client's door and in their room. This safety precaution alerts healthcare providers and visitors that the client is receiving oxygen therapy, reducing the risk of accidents or misunderstandings. Choice A is incorrect because instructing the client to take slow deep breaths is not the appropriate intervention after applying oxygen. Choice C suggests applying Vaseline and gauze, which is unnecessary and not a standard practice. Choice D advising the client to hyperextend the neck, take deep breaths, and cough is not indicated after applying oxygen therapy and could potentially be harmful.
The nurse is caring for a client and wants to assess the neurologic function. Which of the following will give the most information?
- A. Level of consciousness
- B. Doll's eye reflex
- C. Babinski reflex
- D. Reaction to painful stimuli
Correct Answer: A
Rationale: The correct answer is 'Level of consciousness.' Assessing the client's level of consciousness provides crucial information about their neurologic function, including subtle changes in verbal ability, orientation, and responsiveness to commands. Doll's eye reflex is a specific eye movement test used in neurologic assessments but may not provide as much comprehensive information as the client's overall consciousness level. The Babinski reflex is a test used to assess specific spinal cord function rather than overall neurologic function. Reaction to painful stimuli provides information about sensory function and pain response but may not offer as much insight into the client's neurologic status as assessing their level of consciousness.
A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?
- A. The client is observed shaving only one side of his face.
- B. The client is unable to distinguish between two tactile stimuli presented simultaneously.
- C. The client is unable to complete a range of vision without turning his head side to side.
- D. The client is unable to carry out cognitive and motor activity at the same time.
Correct Answer: A
Rationale: Unilateral neglect is a condition where a person ignores one side of their body. In this case, the behavior of shaving only one side of the face indicates neglect of the other side. This behavior is suggestive of unilateral neglect as the individual is failing to attend to one side of their body. Choices B, C, and D are not associated with unilateral neglect. Choice B refers to tactile agnosia, a condition where a person cannot recognize objects by touch, not related to ignoring one side of the body. Choice C describes a visual field cut, which is a different visual deficit. Choice D relates to dual-task interference, not specific to ignoring one side of the body.
On morning rounds, the nurse finds a somnolent client with a Blood glucose of 89 mg/dL. A sulfonurea and a proton pump inhibitor are scheduled to be administered. What is the nurse's best action?
- A. Give the proton pump inhibitor and hold the sulfonurea until the client eats
- B. Hold medications and notify the physician
- C. Arouse the client and give some orange juice with sugar packets added
- D. Give the medications as ordered and re-check blood sugar in one hour
Correct Answer: A
Rationale: The correct action is to give the proton pump inhibitor and hold the sulfonurea until the client eats. Sulfonureas should be held for blood glucose levels below 100 mg/dL until the client has food to prevent hypoglycemia. Giving the proton pump inhibitor is appropriate and does not need to be delayed. Option B is incorrect because holding both medications without taking appropriate action may lead to further complications. Option C is not the best choice as it does not address the need to hold the sulfonurea until the client eats. Option D is incorrect because administering the medications without ensuring the client eats may lead to hypoglycemia.
The client has been taking divalproex (Depakote) for the management of bipolar disorder. The nurse should give priority to monitoring which laboratory test?
- A. Alanine aminotransferase (ALT)
- B. Serum glucose
- C. Serum creatinine
- D. Serum electrolytes
Correct Answer: A
Rationale: The correct answer is Alanine aminotransferase (ALT). Monitoring ALT levels is crucial when a patient is taking divalproex (Depakote) due to the risk of drug-induced hepatitis. Elevated ALT levels indicate liver damage or disorders, which can be a side effect of Depakote. Serum glucose (choice B) is not the priority for monitoring in this case, as the medication does not directly affect glucose levels. Serum creatinine (choice C) is not the most relevant test to monitor for Depakote use; it primarily assesses kidney function. Serum electrolytes (choice D) are important but do not take precedence over monitoring ALT levels when a patient is on Depakote.