Nokea
Which action by the new nurse when initiating continuous electrocardiogram (ECG) monitoring on a client should indicate to the registered nurse the need for further teaching?
- A. Clipping small areas of hair under the area planned for electrode placement
- B. Stating the need to change the electrodes and inspect the skin every 24 hours
- C. Stating the need to use hypoallergenic electrodes for clients who are sensitive
- D. Cleansing the skin with povidone-iodine (Betadine) before applying the electrodes
Correct Answer: D
Rationale: The skin is cleansed with soap and water (not povidone-iodine), denatured with alcohol, and allowed to air-dry before electrodes are applied. The other three options are correct measures.
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The nurse is monitoring the function of a client's chest tube that is attached to a chest drainage system. The nurse notes that the fluid in the water-seal chamber is below the 2-cm mark. What should the nurse determine based on this finding?
- A. There is a leak in the system.
- B. Suction should be added to the system.
- C. This is caused by client pneumothorax.
- D. Water should be added to the chamber.
Correct Answer: D
Rationale: The water-seal chamber should be filled to the 2-cm mark to provide an adequate water seal between the external environment and the client's pleural cavity. The water seal prevents air from reentering the pleural cavity. Because evaporation of water can occur, the nurse should remedy this problem by adding sterile water until the level is again at the 2-cm mark. The other interpretations are incorrect.
The mother of a child with moderate diarrhea asks how to manage her child's illness. Which of the following should the nurse suggest?
- A. Begin clear liquids for 24 hours.
- B. Feed the child bananas, rice, applesauce, and toast.
- C. Offer foods that are low in fat.
- D. Continue the child's regular diet.
Correct Answer: B
Rationale: The BRAT diet (bananas, rice, applesauce, toast) is recommended for moderate diarrhea in children to provide easily digestible, low-fiber foods that help firm stools.
The nurse is instructing an unlicensed assistive personnel on the prevention of postoperative pulmonary complications. Which of the following statements indicates that the assistant has understood the nurse's instructions?
- A. I will turn the client every 4 hours.'
- B. I will keep the client's head elevated.'
- C. I should suction the client every 2 hours.'
- D. I will have the client take 5 to 10 deep breaths every hour.'
Correct Answer: D
Rationale: Deep breathing exercises hourly prevent atelectasis and promote lung expansion, key to preventing pulmonary complications.
The nurse is caring for a client with a new colostomy. Which statement by the client indicates a need for further teaching?
- A. I should change the pouch every 5 to 7 days.'
- B. I can eat high-fiber foods to promote regular bowel movements.'
- C. I should avoid gas-forming foods like beans.'
- D. I need to drink 2 to 3 liters of fluid daily.'
Correct Answer: B
Rationale: High-fiber foods may cause blockages in a new colostomy. The client should start with a low-residue diet and gradually introduce fiber, indicating a need for further teaching.
The nurse is teaching a client with a new diagnosis of type 2 diabetes about foot care. Which of the following instructions should be included? Select all that apply.
- A. Inspect feet daily for cuts or sores.
- B. Wear well-fitting shoes.
- C. Soak feet in hot water daily.
- D. Apply lotion between the toes.
- E. Trim toenails straight across.
Correct Answer: A, B, E
Rationale: Daily inspection, well-fitting shoes, and straight toenail trimming prevent complications. Hot water and lotion between toes increase infection risk.