Nokea
When a client is having a general tonic clonic seizure, the nurse should
- A. Hold the client's arms at their side
- B. Place the client on their side
- C. Insert a padded tongue blade in client's mouth
- D. Elevate the head of the bed
Correct Answer: B
Rationale: Place the client on their side. This position maintains a patent airway and prevents aspiration.
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Which clients can be assigned to share the same room?
- A. The client scheduled for a hysterectomy and the client with a tubal ligation
- B. The client with pneumonia and the client just returned from having a cardiac catheterization
- C. The client with AIDS and the client with bronchiectasis
- D. The client with rheumatoid arthritis being treated with steroids and the client with emphysema
Correct Answer: A
Rationale: Clients with hysterectomy and tubal ligation are both post-surgical, non-infectious, and suitable to share a room. Other pairs involve infectious or immunocompromised conditions, posing risks.
The nurse is preparing a client for a kidney-ureter-bladder x-ray (KUB). What is included in the preparation?
- A. Keeping the client NPO
- B. Explaining the procedure
- C. Catheterizing the client
- D. Administering an enema
Correct Answer: B
Rationale: Explaining the procedure reduces anxiety and ensures cooperation, a key preparation for a non-invasive KUB x-ray.
A client after an electroconvulsive therapy (ECT) treatment.
The nurse should report which observation to the client's physician?
- A. Headache.
- B. Disruption in short- and long-term memory.
- C. Transient confusional state.
- D. Backache.
Correct Answer: D
Rationale: Strategy: You are looking for something unexpected. (1) expected effect (2) expected effect (3) expected effect (4) correct-client undergoing ECT needs to be instructed about what s/he could experience during and after ECT; expected effects include headache, disrupted memory (short- and long-term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes pain better needs to be assessed and reported to the physician
A diabetic client is taking Lantus insulin for regulation of his blood glucose levels. The nurse should know that this insulin will most likely be administered:
- A. Prior to each meal
- B. At night
- C. Midday
- D. Prior to the evening meal
Correct Answer: B
Rationale: Lantus is a long-acting insulin typically administered at night to provide basal coverage. Options A, C, and D are incorrect for its dosing schedule.
During the initial physical assessment on a client who is a Vietnamese immigrant, the nurse notices small, circular, ecchymotic areas on the client's knees. The best action for the nurse to take is to
- A. Ask the client for more information about the nature of the bruises
- B. Ask the client and then the family about the findings
- C. Report the bruising to social services to follow-up
Correct Answer: A
Rationale: Cupping' is practiced by Vietnamese. The principle is to create a vacuum inside a special cup by igniting alcohol-soaked cotton inside the cup. When the flame extinguishes, the cup is immediately applied to the skin of the painful site. The belief: the suction exudes the noxious element. The greater the bruise, the greater the seriousness of the illness.