Nokea
The nurse reinforces education about safety modifications in the home for the spouse of a client diagnosed with Alzheimer disease. What instructions should the nurse include?
- A. Arrange furniture to allow for free movement
- B. Keep frequently used items within easy reach
- C. Lock doors leading to stairwells and outside areas
- D. Place an identifying symbol on the bathroom door
- E. Provide a dark room free of shadows for sleeping
Correct Answer: A,B,C,D
Rationale: Clear pathways (A), accessible items (B), locked doors (C), and bathroom symbols (D) enhance safety. A dark room (E) may increase confusion or fear.
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The best position for the client with a right total hip replacement is:
- A. With the right hip flexed 90°
- B. With the right hip flexed 35°
- C. Supine with pillows supporting the right leg
- D. Sims position with the right leg adducted
Correct Answer: C
Rationale: Supine with pillows supporting the leg prevents dislocation while maintaining alignment. Flexion or adduction risks complications.
The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
- A. Question the order.
- B. Administer the medications.
- C. Administer them separately.
- D. Contact the pharmacy.
Correct Answer: B
Rationale: Lisinopril and furosemide are commonly prescribed together for hypertension, as lisinopril is an ACE inhibitor that reduces blood pressure, and furosemide is a diuretic that reduces fluid volume. There is no contraindication for administering them concomitantly, so answer A is incorrect. Administering them separately is unnecessary, so answer C is incorrect. Contacting the pharmacy is not needed unless there is a supply issue, so answer D is incorrect.
An 8-year old is admitted with drooling, muffled phonation and a temperature of 102.6°. The nurse should immediately notify the doctor because the child's symptoms are suggestive of:
- A. Strep throat
- B. Epiglottitis
- C. Laryngotracheobronchitis
- D. Bronchiolitis
Correct Answer: B
Rationale: Drooling, muffled phonation, and fever suggest epiglottitis, a medical emergency requiring immediate intervention due to the risk of airway obstruction.
A client complains of some discomfort after a below the knee amputation. Which action by the nurse is most appropriate initially?
- A. Conduct guided imagery or distraction
- B. Ensure that the stump is elevated the first day post-op
- C. Wrap the stump snugly in an elastic bandage
- D. Administer opioid narcotics as ordered
Correct Answer: B
Rationale: Ensure that the stump is elevated the first day post-op. This priority intervention prevents pressure caused by pooling of blood, thus minimizing the pain. Without this measure, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. Opioid narcotics are given for severe pain.
The nurse is reviewing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan?
- A. Canned baby food is more expensive than food prepared at home
- B. Finger foods can be introduced before the child has teeth
- C. New foods should be introduced at least 5-7 days apart
- D. Rice cereal can be mixed with cow's milk to increase nutritional intake
Correct Answer: C
Rationale: Introducing new foods 5-7 days apart (C) prevents allergic reactions by identifying triggers, making it the priority. Cost (A), finger foods (B), and cow's milk (D, not recommended before 12 months) are secondary.