Nokea
The oncoming nurse receives report on a group of clients. Which client should have priority during the nurse's rounds?
- A. a client who just returned from surgery for an open appendectomy
- B. a client with a blood pressure of 184/86 who has not received the morning dose of lisinopril
- C. a client who is on a 100% non-rebreather mask with an oxygen saturation level of 96%
- D. a client with COPD who is on 2 L of oxygen via nasal cannula with an oxygen saturation level of 90%
Correct Answer: A
Rationale: A client just returning from surgery requires immediate assessment for postoperative complications, making them the priority.
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The nurse is developing a care plan for a client with hepatitis A. The nurse knows that the primary routes of transmission of this hepatitis virus are which of the following? Select all that apply.
- A. sputum
- B. blood
- C. feces
- D. contaminated food
Correct Answer: C,D
Rationale: Hepatitis A is transmitted primarily via the fecal-oral route, through contaminated food or water (D) and feces (C).
If a group includes only members selected on a specific basis, such as women with a history of domestic or partner abuse, how is this type of group classified?
- A. Homogeneous
- B. Closed
- C. Heterogeneous
- D. Task
Correct Answer: A
Rationale: A group with members sharing a specific characteristic, like domestic abuse history, is homogeneous (A). Closed (B) refers to membership limits, heterogeneous (C) to diversity, and task (D) to purpose.
A client has recurrent episodes of constipation and fecal impaction. The nurse is assisting the client with a bowel-training regimen. Which of the following interventions should be included? Select all that apply.
- A. Scheduled toileting
- B. Stool softeners
- C. High-fiber diet
- D. Daily laxatives
- E. Periodic enemas
- F. Routine exercise
Correct Answer: A,B,C,F
Rationale: Bowel training includes scheduled toileting (A), stool softeners (B), high-fiber diet (C), and routine exercise (F) to promote regular bowel movements. Daily laxatives (D) and periodic enemas (E) are not preferred long-term.
The physician has ordered sublingual nitroglycerin for a client. Which of the following are contraindications for administration of sublingual or buccal medications? Select all that apply.
- A. Client is edentulous.
- B. Client has mild dementia.
- C. Mucous membranes are red and irritated.
- D. Client is dehydrated.
- E. Client has productive aphasia.
Correct Answer: C,D
Rationale: Red, irritated mucous membranes (C) and dehydration (D) impair sublingual absorption. Edentulous state (A), mild dementia (B), and aphasia (E) do not contraindicate sublingual administration.
The client with preeclampsia is admitted to the unit with an order for magnesium sulfate IV. Which action by the nurse indicates a lack of understanding of magnesium sulfate?
- A. The nurse places a sign over the bed not to check blood pressures in the left arm.
- B. The nurse obtains an IV controller.
- C. The nurse inserts a Foley catheter.
- D. The nurse darkens the room.
Correct Answer: A
Rationale: Avoiding blood pressure checks in one arm is unrelated to magnesium sulfate; the other actions align with monitoring and managing side effects.