Nokea
The sudden onset of which of the following indicates a potentially serious complication for the client receiving an I.V. infusion?
- A. Noisy respirations.
- B. Pupillary constriction.
- C. Halitosis.
- D. Moist skin.
Correct Answer: A
Rationale: Noisy respirations may indicate fluid overload or pulmonary edema, a serious I.V. infusion complication requiring immediate intervention.
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Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply.
- A. Accepting the client while not arguing with the delusion.
- B. Focusing on the feelings or meaning of the delusion.
- C. Focusing on events and topics based in reality.
- D. Confronting the client's beliefs.
- E. Interacting with the client only when he is based in reality.
Correct Answer: A,B,C
Rationale: To manage grandiose delusions, the nurse should accept the client without reinforcing the delusion, focus on the underlying feelings, and redirect to reality-based topics. Confronting beliefs or limiting interaction to reality-based moments can escalate agitation or alienate the client.
A diabetic primigravid client at 38 weeks' gestation asks the nurse why she had a fetal acoustic stimulation during her last nonstress test. Which of the following should the nurse include as the rationale for this test?
- A. To listen to the fetal heart rate
- B. To startle and awaken the fetus
- C. To stimulate mild contractions
- D. To confirm amniotic fluid amount
Correct Answer: B
Rationale: Fetal acoustic stimulation is used to startle and awaken the fetus, prompting movement to assess fetal heart rate reactivity during a nonstress test. It does not directly measure heart rate, stimulate contractions, or assess amniotic fluid.
The physician has ordered a low-potassium diet for a client. Which of the following food choices indicates that the client needs further instruction regarding the diet?
- A. Apple.
- B. Baked potato.
- C. Carrots.
- D. Spinach.
Correct Answer: B
Rationale: Baked potatoes are high in potassium, so choosing them indicates a need for further teaching on a low-potassium diet.
The doctor orders a midstream urine specimen for your client who is an alert, oriented and ambulatory female client. What element should you include in your instructions to this client on the proper manner to collect this specimen?
- A. The need to cleanse the perineal area with circular wipes.
- B. The need to cleanse the perineal area from the 'dirtiest' to the 'cleanest'.
- C. The need to use a new antiseptic wipe for each wipe from the inner to the outer labia.
- D. The need to use a new antiseptic wipe for each wipe from the outer to the inner labia.
Correct Answer: C
Rationale: For a midstream urine specimen, the perineal area should be cleansed from front to back (inner to outer labia) using a new antiseptic wipe for each stroke to prevent contamination.
A client who is a computer operator has developed carpal tunnel syndrome. The nurse can instruct the client to relieve the pain by managing:
- A. Decreased circulation to the brachial nerve.
- B. Muscle atrophy resulting from disuse.
- C. Median nerve compression.
- D. Progressive flexion contracture of the wrist.
Correct Answer: C
Rationale: Carpal tunnel syndrome results from median nerve compression, and managing this (e.g., with splints or exercises) relieves pain.