Nokea
The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first
- A. Assess the client's airway.
- B. Call for help.
- C. Establish that the client is unresponsive.
- D. See if anyone saw the client fall.
Correct Answer: C
Rationale: Checking responsiveness is the first step in assessing the situation.
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To determine if chilling is the result of an emerging complication or of infusing cold blood, what action is essential?
- A. Monitoring the client’s temperature before,during and after the transfusion.
- B. Documenting the client’s temperature after the transfusion.
- C. Documenting the temperature of the blood before the transfusion.
- D. Comparing the client’s temperature with the temperature of the blood.
Correct Answer: A
Rationale: The correct answer is A because monitoring the client’s temperature throughout the transfusion helps identify complications.
For your patient with a CD4 count, less than 200, the most important nursing assessment would include
- A. Bowel movements.
- B. Urinary output.
- C. Fever.
- D. Blood pressure.
Correct Answer: C
Rationale: Fever can indicate opportunistic infections in immunocompromised patients.
Complications of self-induced vomiting in binge eating disorder include which of the following?
- A. Fluid and electrolyte disorders
- B. Damage to teeth
- C. Constipation
- D. Cardiac problems
Correct Answer: B
Rationale: Frequent vomiting exposes teeth to stomach acid, causing enamel erosion and dental damage.
A patient is diagnosed with Bell's palsy and has signs of unilateral facial paralysis and is unable to close his right eye. What eye care is required?
- A. The patient will need to instill artificial teardrops and use an eye patch.
- B. None, since the symptoms will disappear in a few weeks.
- C. Increase fluid intake to prevent dryness of the eye.
- D. Wear sunglasses.
Correct Answer: A
Rationale: Protecting the exposed eye is crucial in Bell's palsy to prevent corneal damage.
Patients with pernicious anemia are treated with
- A. Oral iron.
- B. Oral folic acid.
- C. Parenteral vitamin B12.
- D. Oral prednisone.
Correct Answer: C
Rationale: Vitamin B12 deficiency in pernicious anemia requires parenteral administration.