Nokea
The nurse reinforces teaching for a client newly prescribed buspirone for generalized anxiety disorder. Which client statement indicates that teaching has been effective?
- A. Driving is not recommended until I stop taking this medication.
- B. If I experience a panic attack I should take an extra dose of medication.
- C. It will be 2-4 weeks before I feel the full effect of this medication.
- D. Withdrawal symptoms will occur if I abruptly stop taking this medication.
Correct Answer: C
Rationale: Buspirone takes 2-4 weeks for full effect, indicating effective teaching. Extra doses are unsafe, driving is generally allowed, and withdrawal is minimal.
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An adult is receiving intermittent tube feedings. When the nurse aspirates and measures the gastric contents, the client's wife asks the nurse what she is doing. What information is most important to include in the response?
- A. The procedure is done to test that the tube is working.
- B. The procedure is done to check the placement of the tube.
- C. The procedure is done to check for gastric emptying.
- D. The procedure is done to clear the line.
Correct Answer: B
Rationale: Aspirating gastric contents verifies tube placement, the most critical step to prevent aspiration during feedings.
The nurse is preparing to perform wound irrigation for a client who sustained a scalp laceration. Which of the following actions should the nurse take?
- A. Hold the syringe 8 in (20.3 cm) above the wound.
- B. Use a 10 mL syringe to draw up the irrigation solution.
- C. Position the client so the irrigation solution flows from the most to least contaminated area.
- D. Flush the wound with low, continuous pressure and dry the surrounding area with sterile gauze.
Correct Answer: C
Rationale: Irrigation should flow from the least to most contaminated area to prevent infection spread. Other options are incorrect techniques.
The nurse is caring for a 6-year-old who is postoperative open right tibial fracture reduction with cast placement. Which finding requires priority action?
- A. Blood-tinged stain on the inner aspect of the cast
- B. Capillary refill of 2 seconds on the affected extremity
- C. Mild swelling of toes on the right foot
- D. Pain of 9/10 an hour after a dose of morphine
Correct Answer: D
Rationale: Severe pain (9/10) despite recent morphine suggests complications like compartment syndrome, requiring immediate action. Other findings are less urgent.
The nurse is planning care for a 6-month-old client admitted with bacterial meningitis. Which nursing action is the priority?
- A. Apply padding to the crib side rails
- B. Document head circumference daily
- C. Implement a low-stimuli environment
- D. Initiate antibiotic therapy as prescribed
Correct Answer: D
Rationale: Prompt antibiotic therapy is critical to treat bacterial meningitis and prevent complications or death, making it the priority. A, B, and C are important but secondary; padding prevents injury, daily head circumference monitors for hydrocephalus, and a low-stimuli environment reduces seizure risk, but none address the infection directly.
A client wanders away from home and is found 48 hours later sleeping on a park bench. The client is awake, alert, and oriented but cannot recall name, address, or events that occurred in the past 2 days. What is the priority nursing action?
- A. Contact family members
- B. Encourage the client to recall recent events
- C. Measure vital signs
- D. Monitor mental status
Correct Answer: C
Rationale: Measuring vital signs is the priority to ensure physiological stability in a client with amnesia, which may indicate a medical emergency like transient global amnesia.