Nokea
Which action by the client indicates an acceptance of his recent amputation?
- A. He verbalizes acceptance.
- B. He looks at the operative site.
- C. He asks for information regarding prosthesis.
- D. He remains silent during dressing changes.
Correct Answer: C
Rationale: Asking about a prosthesis indicates the client is planning for future mobility and adapting to the amputation, a strong sign of acceptance. Verbalizing acceptance is less specific, looking at the site may indicate curiosity or distress, and silence suggests denial or withdrawal.
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The nurse is preparing discharge teaching for the parents of a newborn. Which of the following information should the nurse provide to the parents regarding the accuracy of a PKU (phenylketonuria) Test ?
- A. Breast-fed babies need to be a week old for the Test , and infants on formula can be Test ed in three days.
- B. The Test will need to be repeated at six weeks and at the three-month.pnlcheck-up.
- C. Blood will be drawn at three one-hour intervals; there is no specific preparation.
Correct Answer: A
Rationale: formula or cow's milk contains high phenylalanine levels; Test can be done after three days of formula intake; if mother is breastfeeding, infant will need to return in one week for Test
The nurse is teaching unlicensed personnel about preventing the spread of disease in the health care environment. The nurse knows that the personnel understand when they state that which is the most important way to prevent the spread of disease?
- A. Isolating infected clients
- B. Consistently washing hands
- C. Wearing a gown when there is a question of a client with a questionable disease
- D. Wearing gloves whenever giving care
Correct Answer: B
Rationale: Hand washing is the most effective way to prevent disease transmission, breaking the chain of infection in healthcare settings.
The physician has ordered Prednisone 50 mg daily to promote diuresis in a client with nephrotic syndrome. The nurse should administer the medication:
- A. In a single dose at bedtime
- B. With a snack or glass of milk
- C. With water to promote absorption
- D. Prior to arising in the morning
Correct Answer: B
Rationale: Prednisone, a steroid, should be given with a snack or meal to prevent gastric irritation. Answer C would cause pain and gastric upset, making it incorrect. Answers A and D do not include providing food with the medication, so they are incorrect.
The nurse is providing home care to a confused older adult. The family members have tied the client in a chair with a large leather belt. They say the client wanders if he isn't restrained. What initial nursing action is most appropriate?
- A. Report the family to family protective services.
- B. Congratulate the family on solving the problem.
- C. Help the family think of ways to make the environment safer for the client.
- D. Tell the family that they are not allowed to restrain the client with a leather belt.
Correct Answer: C
Rationale: Helping the family create a safer environment addresses wandering non-restrictively, promoting safety and autonomy. Reporting, praising, or prohibiting are less constructive.
During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?
- A. I have constant blurred vision.
- B. I can't see on my left side.
- C. I have to turn my head to see my room.
- D. I have specks floating in my eyes.
Correct Answer: C
Rationale: I have to turn my head to see my room. Intraocular pressure becomes elevated, producing a progressive loss of the peripheral visual field in the affected eye.