Nokea
What is the nurse's best action for a client with a migraine headache?
- A. Administer oxygen.
- B. Provide a quiet, dark environment.
- C. Encourage fluid restriction.
- D. Apply a warm compress.
Correct Answer: B
Rationale: A quiet, dark environment reduces stimuli that exacerbate migraine symptoms.
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The nurse is developing a discharge plan about home care with a client who has lymphoma. The nurse should emphasize which of the following?
- A. Use analgesics as needed.
- B. Take a shower with perfumed shower gel.
- C. Wear a mask when outside of the home.
- D. Take an antipyretic every morning.
Correct Answer: A
Rationale: Clients with lymphoma may experience pain from lymph node enlargement or treatment. Using analgesics as needed is appropriate for symptom management. Perfumed shower gel may irritate skin, masks are not routinely needed, and daily antipyretics are unnecessary unless fever persists.
The client with an ileal conduit will be using a reusable appliance at home. The nurse should teach the client to clean the appliance routinely with the client to clean the appliance routinely.
- A. Baking soda.
- B. Soap.
- C. Hydrogen peroxide.
- D. Alcohol.
Correct Answer: B
Rationale: Soap is safe and effective for cleaning reusable ileal conduit appliances, removing residue without damaging the appliance or irritating the skin.
A client is admitted to the emergency department with a full thickness burn to his right arm. Upon assessment, the arm is edema, the agent is mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10 . The nurse should:
- A. Administer morphine sulfate I.V. push for the severe pain.
- B. Call the physician to report the loss of the radial pulse.
- C. Continue to assess the arm every hour for any additional changes.
- D. Instruct the client to exercise his fingers and wrist.
Correct Answer: B
Rationale: The absence of the radial pulse indicates potential compartment syndrome or vascular compromise, which is a medical emergency requiring immediate physician notification to prevent tissue necrosis.
The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which of the following should be the nurse's first step in planning the dietary instructions?
- A. Determining the client's knowledge level about cholesterol.
- B. Asking the client to name foods that are high in fat, cholesterol, and salt.
- C. Explaining the importance of complying with the diet.
- D. Assessing the client's and family's typical food preferences.
Correct Answer: D
Rationale: Assessing food preferences ensures the dietary plan is tailored and practical.
A client has developed a hospital-acquired pneumonia. When preparing to administer cephalexin (Keflex) 500 mg, the nurse notices that the pharmacy sent cefazolin (Kefzol). What should the nurse do? Select all that apply.
- A. Administer the cefazolin (Kefzol).
- B. Verify the medication order as written by the physician.
- C. Contact the pharmacy and speak to a pharmacist.
- D. Request that cephalexin (Keflex) be sent promptly.
- E. Return the cefazolin (Kefzol) to the pharmacy.
Correct Answer: B,C,D,E
Rationale: The nurse should verify the order (B), contact the pharmacy (C), request the correct medication (D), and return the incorrect drug (E). Administering cefazolin (A) risks a medication error.