Nokea
What nursing intervention is best to improve communication with a hearingimpaired client?
- A. Talk in a regular voice in the good ear
- B. Talk loudly in the impaired ear
- C. Write down the message
- D. Speak slowly and clearly while facing the client
Correct Answer: D
Rationale:
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A nurse assesses an area of skin over a bony prominence. What finding would
be most concerning?
- A. Redness
- B. Non-blanching
- C. Blanching
- D. Warmth
Correct Answer: A
Rationale:
The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?
- A. The client refused her pain medication this morning and is doing physical therapy.
- B. The client reports a minor headache and states she takes an over-the-counter pain pill at home.
- C. The client reports intermittent flatus and minor abdominal discomfort.
- D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.
Correct Answer: D
Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.
A nurse assesses an audible grating sound (Crepitus) when a client with
osteoarthritis moves his knees. What is the cause of this sound?
- A. A herniated disk in the diseased joint
- B. Pieces of bone and cartilage floating
- C. Popping bursae from standing
- D. Years of an autoimmune process
Correct Answer: A
Rationale:
What nursing intervention is appropriate for a client with systemic lupus
erythematous (SLE)?
- A. Intense cold therapy to the extremities
- B. Encourage ultraviolet (UV) light exposure
- C. Administer topical hydrocortisone
- D. Administer antibiotics
Correct Answer: C
Rationale:
By providing measures to reduce skin breakdown, how does the nurse break the
chain of infection?
- A. Sterilizing the area to reduce the reservoir risk
- B. Maintaining the integrity of a portal of entry
- C. Creating a reservoir to decrease the risk of infection
- D. Creating a susceptible host
Correct Answer: B
Rationale: