Nokea
Which client should receive a private room?
- A. A client with diabetes
- B. A client with Cushing's disease
- C. A client with Graves' disease
- D. A client with gastric ulcers
Correct Answer: D
Rationale: A client with gastric ulcers may have Helicobacter pylori infection, which can be contagious and requires isolation precautions. Clients with diabetes, Cushing's disease, or Graves' disease do not typically require private rooms unless they have a contagious condition.
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The nurse is teaching a client about the toxicity of digoxin. Which one of the following statements made by the client to the nurse indicates more teaching is needed?
- A. I may experience a loss of appetite.'
- B. I can expect occasional double vision.'
- C. Nausea and vomiting may last a few days.'
- D. I must report a bounding pulse of 62 immediately.'
Correct Answer: D
Rationale: Slow heart rate is related to increased cardiac output and an intended effect of digoxin. The ideal heart rate is above 60 BPM with digoxin. The client needs further teaching.
An older woman hospitalized with a fractured left hip, placed in Buck's traction with a seven-pound weight while awaiting surgery.
Which of the following instructions for moving should be discussed by the nurse to encourage the patient to participate in her care?
- A. Pull up on the overhead trapeze while you push down on your right foot to lift your body.'
- B. With your right arm, grasp the bedside rail on the opposite side and pull yourself over gently.'
- C. I'll raise the head of the bed 45°, and then you lean forward and rotate your hips to the left.'
- D. Swing your right leg over your left leg, and turn from your waist down, keeping your legs straight.'
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-body must move as single, straight unit (2) turning or twisting from the waist down interferes with countertraction (3) prevents proper pull of weights (4) can't turn from side to side, can only move up and down
A client's Salem sump tube (nasogastric).
Which of the following findings would indicate to the nurse that a client's Salem sump tube (nasogastric) was functioning effectively?
- A. Fluctuation of the fluid level in the water seal chamber.
- B. Active bubbling in the suction bottle.
- C. The presence of a hissing sound from the blue lumen tube.
- D. A pressure of 25 mm Hg in the esophageal balloon.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to a Salem sump tube. (1) Salem sump tube is not a water-sealed drainage system (2) associated with a water-sealed drainage system (3) correct-'hissing' sound is indicative that air is freely exiting the airway, purpose is to provide continuous steady suction without pulling gastric mucosa (4) is relevant to a Sengstaken-Blakemore tube
The nurse has received her assignment for the day and is to care for the following clients. Which client should the nurse go to first?
- A. A 56-year-old who was admitted last evening vomiting blood; the night nurse says he has had no emesis for the last four hours
- B. A 65-year-old who had hip replacement surgery two days ago
- C. A 68-year-old who fell yesterday and is scheduled for hip surgery later this morning
- D. A 69-year-old who was admitted last evening with severe right upper quadrant and right scapular pain
Correct Answer: A
Rationale: The client with recent hematemesis is at risk for recurrent bleeding, requiring immediate assessment to ensure stability, prioritizing over stable surgical or presurgical clients.
The charge nurse is planning assignments on a medical unit. The client with should be assigned to the unlicensed assistive personnel (UAP).
- A. difficulty swallowing after a mild stroke
- B. an order of enemas until clear prior to colonoscopy
- C. an order for a post-op abdominal dressing change
- D. transfer orders to a long term facility
Correct Answer: B
Rationale: The UAP can be assigned routine tasks which have predictable outcomes, such as administering enemas.