Nokea
What does using random weights help to prevent when weighing a client diagnosed with binge eating?
- A. Dehydration
- B. Lying about weight
- C. Water loading
- D. Denial of weight loss
Correct Answer: B
Rationale: Random weights reduce opportunities for clients to manipulate or lie about their actual weight.
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The charge nurse assigned the care of a client with acute renal failure and hypernatremia to you, a newly graduated RN. Which actions can you delegate to the nursing assistant? (Choose all that apply.)
- A. Provide oral care every 3-4 hours
- B. Monitor for indications of dehydration
- C. Administer 0.45% saline by IV line
- D. Assess daily weights for trends
Correct Answer: A
Rationale: Oral care and assessing daily weights are tasks that can be delegated to a nursing assistant. Monitoring for dehydration and administering IV fluids require more advanced clinical skills.
Anne asks how a chest x-ray would help the physician examine her heart. You respond by saying
- A. A chest x-ray is used to rule out that a fractured rib caused your pain.
- B. The chest x-ray is an error. I will cancel the order.
- C. A chest x-ray is used to detect the size and position of the heart.
- D. All patients who are admitted must have a chest x-ray.
Correct Answer: C
Rationale: Chest x-rays provide information about heart size and position.
In discharge teaching for cataract surgery, the client and family should be told to immediately report which symptom to the physician?
- A. Scratchy sensation in the operative eye
- B. Loss of depth perception with the patch in place
- C. Inadequate vision 6-8 hours after the patch is removed
- D. Intense pain not relieved by prescribed medications
Correct Answer: D
Rationale: Intense pain unrelieved by medication may indicate complications such as infection or increased intraocular pressure.
A client has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?
- A. Continuous bubbling in the water-seal chamber
- B. Occasional bubbling in the water-seal chamber
- C. Constant bubbling in the suction-control chamber
- D. Fluctuations in the fluid level in the water-seal chamber
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Continuous bubbling in the water-seal chamber indicates air leaks, which can lead to pneumothorax.
2. Occasional bubbling in the water-seal chamber is normal as air exits the pleural space.
3. Constant bubbling in the suction-control chamber indicates high suction pressure, not a complication.
4. Fluctuations in the fluid level in the water-seal chamber are expected during normal respiration.
What is the most appropriate response to Harold Smith asking what he can do to prevent black lung disease?
- A. Suggest he seek symptomatic medical treatment
- B. Reassure him that black lung is a disease of the past
- C. Encourage him to change jobs
- D. Recommend psychologic counseling
Correct Answer: C
Rationale: Changing jobs eliminates exposure to coal dust, preventing black lung.