Nokea
The school nurse monitors an 8-year-old with a history of asthma. The nurse notes mild wheezing and coughing. Which action should the nurse perform first?
- A. Call the health care provider
- B. Determine the client's peak expiratory flow
- C. Notify the client's parents
- D. Remind the client about avoiding triggers
Correct Answer: B
Rationale: Measuring peak expiratory flow assesses asthma severity first. Calling the provider , notifying parents , or discussing triggers follows based on the assessment.
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The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question?
- A. You need to regain your strength before attempting such exertion.'
- B. When you can climb 2 flights of stairs without problems, it is generally safe.'
- C. Have a glass of wine to relax you, then you can try to have sex.'
- D. If you can maintain an active walking program, you will have less risk.'
Correct Answer: B
Rationale: There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.
During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence?
- A. What degree of supervision for basic care do you think you need?
- B. Let's review your skills check-list for type and level of skill
- C. Are you comfortable working independently?
- D. What client care tasks or assignments do you prefer?
Correct Answer: B
Rationale: The nurse needs to know that the employee has competence in certain tasks. One way to do this is to do mutual review of documented skills.
At the geriatric day care program a client is crying and repeating 'I want to go home. Call my daddy to come for me.' The nurse should
- A. Inform the client that she must wait until the program ends at 5:00 pm to leave
- B. Give the client simple information about what she will be doing
- C. Tell the client you will call someone to come for her and suggest joining the exercise group while she waits
- D. Firmly direct the client to her assigned group activity
Correct Answer: C
Rationale: Tell the client you will call someone to come for her and suggest joining the exercise group while she waits. This uses comforting and distraction to reduce distress in dementia.
The nurse is about to medicate a client who is to have surgery today. The client says, 'I do not understand what the doctor is going to do,' and asks the nurse to explain specific details of the surgery. The client has already signed an operative permit. What is the best action for the nurse to take at this time?
- A. Attempt to answer the client's questions
- B. Notify the physician of the client's concerns prior to medicating the client
- C. Reassure the client that the physician is well respected and very competent
- D. Suggest that the client ask the physician her questions when in the operating room
Correct Answer: B
Rationale: The client's lack of understanding indicates a need for clarification before proceeding. Notifying the physician ensures informed consent is valid, delaying medication that may impair judgment.
The nurse is caring for a client with a seizure disorder. Which of the following seizure precautions should the nurse implement? Select all that apply.
- A. Apply pads to the side rails.
- B. Remove all linen from the bed.
- C. Set up bedside suction equipment
- D. Prepare to apply soft limb restraints.
- E. Ensure supplemental oxygen is available.
Correct Answer: A,C,E
Rationale: Padded rails prevent injury. Suction clears airways. Oxygen supports breathing. Removing linen is unnecessary, and restraints are a last resort due to injury risk.