Nokea
The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistants. The RN should care for which of the following patients?
- A. A patient with a chest tube who is ambulating in the hall.
- B. A patient with a colostomy who requires assistance with an irrigation.
- C. A patient with a right-sided cerebral vascular accident (CVA) who requires assistance with bathing.
- D. A patient who is refusing medication to treat cancer of the colon.
Correct Answer: D
Rationale: requires assessment skills of the RN
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Which of the following should the nurse include in his teaching plan for the client taking Vasopressin (Lypressin)?
- A. The client will need to take her medication with meals.
- B. The client will need to learn how to check the specific gravity of her urine.
- C. The client will need to modify her daily activities.
- D. The client will need to learn the proper method of drug administration.
Correct Answer: D
Rationale: Vasopressin is often administered nasally or by injection, so teaching the proper administration method is essential.
The nurse asks a client with a history of alcoholism about recent drinking behavior. The client states 'I didn't hurt anyone. I just like to have a good time, and drinking helps me to relax.' The client is using which defense mechanism?
- A. Denial
- B. Projection
- C. Intellectualization
- D. Rationalization
Correct Answer: D
Rationale: Rationalization. The client justifies drinking by providing acceptable explanations for unacceptable behavior.
An adult is admitted to the nursing care unit. He begs the nurse to give him a laxative. Which data in the admission assessment contraindicates administration of a laxative?
- A. The client has not had a bowel movement for two days.
- B. The client has a temperature of 100.8°F.
- C. The client is nauseated and vomited before admission.
- D. The client has right lower quadrant abdominal pain.
Correct Answer: D
Rationale: Right lower quadrant pain may indicate appendicitis or other acute conditions; laxatives could worsen the condition, risking perforation. Two days without a bowel movement, mild fever, or nausea do not contraindicate laxatives.
The nurse is caring for a client with a history of peripheral artery disease.
- A. Which symptom is expected in a client with peripheral artery disease?
- B. Warm, red skin on the legs.
- C. Intermittent claudication.
- D. Swelling in the ankles.
- E. Numbness in the arms.
Correct Answer: B
Rationale: Intermittent claudication (leg pain with activity, relieved by rest) is a hallmark of peripheral artery disease due to reduced blood flow. Warm skin and swelling suggest venous issues, and arm numbness is unrelated.
A 70-year-old man with a history of hypertension and closed-angle glaucoma visits the clinic for a routine check-up. Which of the following medications, if ordered by the physician, should the nurse question?
- A. Propranolol (Inderal), 80 mg PO QID.
- B. Verapamil (Nifedipine), 40 mg PO TID.
- C. Tetrahydrozoline (Visine), 2 gtts OU TID.
- D. Timolol (Timoptic solution), 1 gtt OU QD.
Correct Answer: C
Rationale: contraindicated; ophthalmic vasoconstrictor, contraindicated with closed angle glaucoma; use cautiously with hypertension