Nokea
A client experiencing alcohol withdrawal.
Which finding would indicate to the nurse that a client experiencing alcohol withdrawal is in need of more sedation to control the severity of withdrawal symptoms?
- A. Increasing lethargy.
- B. Uncoordinated motor movements.
- C. Elevated pulse rate.
- D. Improved orientation to time and place.
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice and how it relates to alcohol withdrawal. (1) would indicate a need for less sedation and a thorough physical assessment (2) suggests neurological trauma or damage (3) correct-pulse rate is a good indicator of client's progress through withdrawal, increasingly elevated pulse signals impending alcohol withdrawal delirium, requiring more sedation (4) suggests that the client is improving and will subsequently require less sedation
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Which of the following provides the best evidence that the nursing interventions to deal with a client’s self-care deficit in relation to feeding have been effective?
- A. The client eats at least one-half of all meals and drinks a minimum of 2,000 mL/day.
- B. The client’s dentures have been replaced, and he is able to chew.
- C. The client will eat without verbalizing suspicions when a particular nurse sits with him.
- D. The client appears to have increased energy to complete grooming activities.
Correct Answer: A
Rationale: Eating half of meals and drinking 2,000 mL/day is a concrete measure of adequate nutrition, indicating effective interventions. Options B, C, and D are less direct: dentures aid chewing but don’t ensure intake, suspicions suggest unresolved issues, and grooming energy is unrelated.
A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?
- A. I cannot give this medication as it is written. I have no idea of what you mean.
- B. Would you please clarify what you have written so I am sure I am reading it correctly?
- C. I am having difficulty reading your handwriting. It would save me time if you would be more careful.
- D. Please print in the future so I do not have to spend extra time attempting to read your writing.
Correct Answer: B
Rationale: Would you please clarify what you have written so I am sure I am reading it correctly? This is respectful and ensures patient safety.
The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is
- A. Advising client to restrict sodium intake
- B. Taking the blood pressure in the left arm
- C. Elevating her left arm above heart level
- D. Compressing the drainage device
Correct Answer: B
Rationale: Taking the blood pressure in the left arm. Clients who have had a unilateral mastectomy should not have their blood pressure measured on the affected side. This helps avoid the possibility of lymphedema post-operatively and in the future.
The nurse is teaching a client with newly diagnosed diabetes mellitus about foot care. Which of the following instructions should the nurse include?
- A. Soak feet in hot water daily.
- B. Apply lotion between the toes.
- C. Trim toenails with rounded edges.
- D. Inspect feet daily for cuts or sores.
Correct Answer: D
Rationale: Daily foot inspection prevents complications like infections in diabetes. Options A, B, and C risk burns, fungal growth, or ingrown nails.
The nurse is teaching a client with a new diagnosis of asthma about using an albuterol inhaler. Which of the following statements by the client indicates a need for further teaching?
- A. I should shake the inhaler before using it.
- B. I should hold my breath for 10 seconds after inhaling.
- C. I should use the inhaler every 4 hours even if I feel fine.
- D. I should rinse my mouth after using the inhaler.
Correct Answer: C
Rationale: Using albuterol every 4 hours without symptoms is incorrect, as it is a rescue inhaler for acute symptoms, not maintenance. Options A, B, and D are correct: shaking ensures proper dose, holding breath maximizes absorption, and rinsing prevents oral thrush (though more relevant for steroids).