Nokea
The nurse provides a postoperative client with an analgesic medication and darkens the room before the client goes to sleep for the night. The nurse's actions:
- A. help the client's circadian rhythm.
- B. stimulate hormonal changes in the brain.
- C. decrease stimuli from the cerebral cortex.
- D. alert the hypothalamus in the brain.
Correct Answer: C
Rationale: Reduction of environmental stimuli (particularly light and noise) from the cerebral cortex (which can be an area of arousal) facilitates sleep. Sleep occurs when there is a decreased input into this area.
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The nurse is observing the nursing student caring for the client with an artificial eye. What action by the student nurse would require intervention?
- A. Positioning the client lying down to remove the prosthetic eye
- B. Drying the prosthetic eye with gauze before reinsertion
- C. Cleansing the prosthetic eye with normal saline solution
- D. Telling the client to remove the prosthetic eye weekly for cleaning
Correct Answer: B
Rationale: B: The prosthetic eye should be moist to facilitate insertion; drying it could cause trauma to the socket. A: Lying down aids safe removal. C: Normal saline is appropriate for cleansing. D: Periodic removal every 1-3 weeks is recommended.
The nurse is assessing the female client who is 65 inches tall and has a small body frame. Based on the information in the chart illustrated, what is the client's approximate ideal body weight?
Correct Answer: 117
Rationale: Height is 5'5†(65/ 12 = 5 remainder 5). Formula: 105 lb for 5 ft + 5 lb × 5 = 130 lb. Small frame subtracts 10% (130 × 0.1 = 13 lb). 130 − 13 = 117 lb.
Which of the following foods present a problem for a client diagnosed with Celiac Disease?
- A. Butter
- B. Oats or barley cereal
- C. Fresh vegetables
- D. Coffee or tea
Correct Answer: B
Rationale: Celiac disease, or celiac sprue, is a malabsorption disorder affecting the small intestine in which there is a problem with the ingestion of gluten, a protein normally found in grain products such as wheat, rye, oats, or barley. The other choices reflect substances that do not contain gluten and should not pose problems for a client with this disorder.
The LPN is preparing to clean a client's PEG tube. Which of the following tasks should the nurse perform? A. Gently remove crusty drainage from the site. B. Pull the tube in multiple directions to ensure it is secure. C. Thoroughly dry the skin around the tube site with a clean towel. D. Use mild soap to clean around the tube site. E. Apply talcum powder to the tube site.
- A. B, D, E
- B. A, B, C
- C. A, C, D
- D. C, D, E
Correct Answer: C
Rationale: LPNs caring for the PEG tube should be careful to not disrupt the tube, pull on the tube, or apply any ointment or powder near or on the tube. Talcum powder may irritate the stoma.
A nurse is assessing a patient in the ICU. The patient has the following signs: weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?
- A. Hypoglycemic patient
- B. Hyperglycemic patient
- C. Cardiac arrest
- D. End-stage renal failure
Correct Answer: B
Rationale: All of the clinical signs indicate a hyperglycemic condition.