Nokea
When the nurse is caring for a client receiving a neuroleptic medication exhibiting torticollis and involuntary muscle movement, what is the priority nursing action?
- A. Have respiratory support equipment available
- B. Administer an antiemetic medication
- C. Monitor the client’s temperature closely
- D. Administer an antihistamine
Correct Answer: A
Rationale: Have respiratory support equipment available. These side effects could lead to respiratory failure, necessitating immediate respiratory support.
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The nurse is preparing to instill dialysate for a client who is receiving peritoneal dialysis. It would be a priority for the nurse to
- A. place the client in the semi-Fowler position
- B. record the characteristics of the dialysate output
- C. use sterile technique when spiking and attaching the bag of dialysate
- D. ensure that the drainage collection bag is below the level of the abdomen
Correct Answer: C
Rationale: Sterile technique when spiking and attaching the dialysate bag prevents peritonitis, a life-threatening complication. Semi-Fowler positioning, recording output, and bag placement are important but secondary to infection prevention.
A nurse is asked to float to the telemetry unit because the unit is short-staffed. The nurse is not familiar with this client population and is concerned about providing safe client care. What is the best action by the nurse?
- A. Accept the assignment and ask about what skills need to be performed
- B. Ask the nurse supervisor if a more experienced nurse can go instead
- C. Read the policy and procedure book for the unit before providing care
- D. Refuse to float to the unit because of concerns about client safety
Correct Answer: A
Rationale: Accepting the assignment and clarifying required skills ensures safe care with support, addressing concerns proactively. Refusing or deferring may disrupt staffing, and reading policies delays care.
The nurse is reinforcing teaching to a client with a history of diverticulitis about lifestyle changes the client should make to reduce the risk of future episodes. Which information should the nurse reinforce to reduce the risk of future episodes? Select all that apply.
- A. Drink plenty of fluids
- B. Exercise regularly
- C. Follow a low-fiber diet
- D. Increase whole grains, fruits, and vegetables in the diet
- E. Increase intake of red meat
Correct Answer: A,B,D
Rationale: Fluids, exercise, and high-fiber foods (whole grains, fruits, vegetables) prevent constipation and reduce diverticulitis risk. Low-fiber diets and red meat increase risk by promoting constipation and inflammation.
The nurse is planning care for a client who is taking cyclosporin (Neoral). What would be an appropriate nursing diagnosis for this client?
- A. Alteration in body image
- B. High risk for infection
- C. Altered growth and development
- D. Impaired physical mobility
Correct Answer: B
Rationale: Cyclosporin (Neoral) inhibits normal immune responses. Clients receiving cyclosporin are at risk for infection.
All of the following tasks need to be done. Which one can the LPN/LVN safely delegate to the certified nursing assistant (CNA)?
- A. Tube feeding for a client with a nasogastric tube
- B. Routine vital signs for a group of clients
- C. Blood pressure monitoring for a client who is in congestive heart failure
- D. Wound care for a client with a stage III decubitus ulcer
Correct Answer: B
Rationale: Routine vital signs are within a CNA's scope of practice. Tube feeding, specialized blood pressure monitoring, and wound care require nursing judgment and skills.