Nokea
The nurse reviews a client's medical history and identifies a diagnosis of presbycusis. The nurse should integrate which intervention in the care plan?
- A. Have educational materials in large print
- B. Provide an eye patch to the affected eye
- C. Request food be seasoned with herbs
- D. Move closer to the better-hearing ear
Correct Answer: D
Rationale: Presbycusis is age-related hearing loss, so moving closer to the better-hearing ear facilitates communication. Large print materials and eye patches address vision issues, and herb-seasoned food is unrelated.
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Which of the following medications should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy?
- A. Sodium phosphate.
- B. Calcium gluconate.
- C. Echothiophate iodide.
- D. Sodium bicarbonate.
Correct Answer: B
Rationale: Calcium gluconate is used to treat tetany by correcting hypocalcemia, which causes muscle spasms and tingling.
The nurse should instruct the client to eat which of the following foods to obtain the best supply of vitamin B12?
- A. Whole grains.
- B. Green leafy vegetables.
- C. Meats and dairy products.
- D. Broccoli and brussels sprouts.
Correct Answer: C
Rationale: Vitamin B12 is primarily found in animal products, such as meats and dairy products, making them the best dietary sources. Whole grains, green leafy vegetables, broccoli, and brussels sprouts contain little to no vitamin B12. Clients with B12 deficiency, such as those with pernicious anemia, should be encouraged to consume meats and dairy to meet their B12 needs.
The nurse is preparing to administer an intramuscular (IM) injection into the client's vastus lateralis. The nurse is correct in identifying the landmark by
- A. palpating to find greater trochanter and knee joints; divide the vertical distance between these two landmarks into thirds; inject into the middle third.
- B. locating the acromion process; inject only into the upper third of muscle that begins about two fingerbreadths below the acromion.
- C. locating the greater trochanter, iliac tubercle, and iliac crest; places palm over the greater trochanter, over iliac tubercle, along the ileum; inject into center of V formed by the fingers.
- D. displacing the skin by pulling the skin down or to one side about 1 inch with the non-dominant hand before administering the injection.
Correct Answer: A
Rationale: The vastus lateralis is correctly located by dividing the thigh into thirds between the greater trochanter and knee, with the middle third being the injection site.
A client receiving chemotherapy for metastatic colorectal cancer has had 2 days of vomiting. Assessment findings include: irregular pulse of 120, blood pressure 88/48, respiratory rate of 14, serum potassium of 2.9 mEq/L, and arterial blood gas€”pH 7.46, PCO‚‚ 45, PO‚‚ 95, bicarbonate level 29 mEq/L. Which of the following interventions is appropriate for the nurse to administer to the client?
- A. Oxygen at 4 L per nasal cannula.
- B. Potassium 40 mEq PO now.
- C. 5% Dextrose in 0.45% Normal Saline with KCl 40 mEq/L at 125 mL/hour.
- D. NaHCO‚ƒ 75 mEq IV.
Correct Answer: C
Rationale: Hypokalemia (2.9 mEq/L) and hypotension (88/48) due to vomiting require I.V. fluid and potassium replacement (D5 0.45% NS with KCl) to correct electrolyte imbalance and dehydration. The alkalosis (pH 7.46) does not require bicarbonate, and oral potassium is unsafe with vomiting.
What is the priority nursing action for a client with a suspected brain tumor?
- A. Administer pain medication.
- B. Monitor neurological status.
- C. Provide emotional support.
- D. Restrict physical activity.
Correct Answer: B
Rationale: Monitoring neurological status is the priority to detect changes associated with a brain tumor.