Nokea
Upon entering a client's room, the nurse finds the client lying on the floor. What is the first action the nurse should implement?
- A. Call for help to get the client back in bed
- B. Assist the client back to bed
- C. Establish if the client is responsive
- D. Ask the client what happened
Correct Answer: C
Rationale: Establishing responsiveness ensures the client’s immediate safety and guides further actions. Other steps follow after assessing the client’s condition.
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The nurse is recommending respite care to a client and their caregiver. The nurse understands that this care is designed to
- A. Improve the quality of life of clients and families who are experiencing problems related to life-threatening illnesses.
- B. Provide a variety of health and social services to specific patient populations.
- C. Have clients live with comfort, independence, and dignity while easing the pain of terminal illness.
- D. Offers short-term relief by providing caregivers who support the ill, disabled, or frail older adults time to relax.
Correct Answer: D
Rationale: Respite care provides temporary relief for caregivers, allowing them rest. Other options describe palliative or comprehensive care services.
The nurse cares for geriatric clients. What would the nurse emphasize as an increased risk for this client population?
- A. Blepharitis and chalazion
- B. Myopia and strabismus
- C. Exophthalmos and presbyopia
- D. Glaucoma and cataracts
Correct Answer: D
Rationale: Glaucoma and cataracts are common age-related eye conditions, increasing vision loss risk. Other conditions are less prevalent or age-specific.
The nurse is caring for a client three hours postoperative following a laparoscopic appendectomy. Which of the following client data indicates the client is ready for discharge home?
- A. Positive gag reflex
- B. Hypoactive bowel sounds
- C. Blood pressure 90/60 mm Hg
- D. Incisional pain '2' on a scale of 0 to 10
- E. Urinary output of 240 mL since surgery
Correct Answer: A,D,E
Rationale: A positive gag reflex indicates airway protection, mild incisional pain (2/10) suggests adequate pain control, and sufficient urinary output (240 mL) indicates renal function, all supporting discharge readiness. Low blood pressure (90/60 mm Hg) suggests instability, and hypoactive bowel sounds are expected but not a discharge criterion.
The nurse is caring for a client with a Sengstaken-Blakemore tube. The nurse performs safety checks at the beginning of the shift and ensures which priority item is readily available at the bedside?
- A. Trach kit
- B. Scissors
- C. Obturator
- D. Yankauer suctioning
Correct Answer: B
Rationale: A Sengstaken-Blakemore tube is used for esophageal variceal bleeding and has balloons that can cause airway obstruction if inflated improperly. Scissors must be at the bedside to cut the tube in an emergency. Trach kits, obturators, and Yankauer suction are not relevant.
The nurse is preparing a staff education program about physiological responses of stress. Which of the following is a physiological alteration that can occur with stress?
- A. Decreased visual acuity
- B. Increased peristalsis
- C. Decreased glucocorticoids
- D. Hyperglycemia
Correct Answer: D
Rationale: Stress triggers hyperglycemia via cortisol release. Visual acuity and peristalsis are not directly affected, and glucocorticoids increase, not decrease.