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The wife of a man who is comatose following a head injury asks the nurse if she should visit him since he is unresponsive. How should the nurse reply initially?
- A. Explain that since he is unresponsive there is no need for her to be here
- B. Tell her that the nurse will call if there is any change
- C. Suggest that her presence is important even though he seems unaware
- D. Recommend that she ask his coworkers to visit
Correct Answer: C
Rationale: Presence of loved ones may provide comfort and stimulate awareness in comatose patients, supporting family involvement. Other responses discourage visitation.
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Steam inhalation is prescribed for a client. Which of the following safety precautions should the nurse include in the client's instructions?
- A. Use distilled water in the humidifier.
- B. Keep the humidifier filled to the top with water.
- C. Turn the humidifier off when not in use.
- D. Clean the humidifier every 2 weeks.
Correct Answer: C
Rationale: Turning off the humidifier when not in use prevents electrical hazards and bacterial growth. Distilled water is ideal but not critical, overfilling is unnecessary, and cleaning frequency depends on use.
The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation?
- A. Chills
- B. Scant lochia rubra
- C. Thirst and fatigue
- D. Temperature of 100.2°F (37.9°C)
Correct Answer: B
Rationale: During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia rubra suggests that large clots are blocking the lochial flow. After delivery, vasomotor changes may cause a shaking chill. Thirst, fatigue, and a temperature of up to 100.4°F (38°C) also are common at 24 hours postpartum.
The nurse understands that the patient with esophageal varices should not be given food such as:
The nurse understands that the patient with esophageal varices should not be given food such as:
- A. Crackers
- B. Purred food
- C. Liquid
- D. Soft
Correct Answer: A
Rationale: Crackers, being rough, can irritate or rupture fragile esophageal varices.
The school nurse is teaching a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates that further teaching is necessary?
- A. I should have a bottle of Ipecac for each of my children.'
- B. I should induce vomiting if my child swallows lighter fluid.'
- C. Giving my child water or milk may help dilute the poison.'
- D. Proper storage is the key to poison prevention in the home.'
Correct Answer: B
Rationale: Inducing vomiting after ingesting hydrocarbons like lighter fluid is contraindicated due to the risk of aspiration, which can cause severe lung damage. Choice A is correct (Ipecac dosing is appropriate), choice C is accurate (dilution can help), and choice D is true (locked storage prevents poisoning). Further teaching is needed for choice B.
An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client
- A. in semi-Fowler's position.
- B. prone, with the head turned to the side.
- C. with the head of the bed elevated 45° and the neck extended.
- D. supine, with the head in the midline position.
Correct Answer: A
Rationale: Semi-Fowler’s position (30°–45° elevation) promotes lung expansion and reduces the risk of airway obstruction or aspiration post-bronchoscopy. Prone (B) limits respiratory assessment, neck extension (C) risks airway obstruction, and supine (D) is less optimal for breathing.