Nokea
Which instruction is most applicable after symptoms are relieved?
- A. Carry heavy objects away from your center of gravity.
- B. Lift with your knees bent and your back straight.
- C. Create a base of support by keeping your feet together.
- D. Select a soft, spongy mattress for your bed.
Correct Answer: B
Rationale: Lifting with knees bent and back straight prevents re-injury to the lumbar spine after a herniated disk.
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Which client statement indicates a need for further teaching about post-craniotomy care?
- A. I'll avoid coughing forcefully.'
- B. I'll sleep with my head elevated.'
- C. I can lift heavy objects after a week.'
- D. I'll report severe headaches immediately.'
Correct Answer: C
Rationale: Lifting heavy objects post-craniotomy can increase intracranial pressure; clients should avoid this for several weeks.
The nurse is preparing to administer acetaminophen (Tylenol) to a client diagnosed with a stroke who is complaining of a headache. Which intervention should the nurse implement first?
- A. Administer the medication in pudding.
- B. Check the client's armband.
- C. Crush the tablet and dissolve in juice.
- D. Have the client sip some water.
Correct Answer: B
Rationale: Checking the armband (B) ensures patient safety before medication administration. Pudding (A), crushing (C), or sipping water (D) follow identity confirmation.
The nurse is caring for several clients on a medical unit. Which client should the nurse assess first?
- A. The client with ALS who is refusing to turn every two (2) hours.
- B. The client with abdominal pain who is complaining of nausea.
- C. The client with pneumonia who has a pulse oximeter reading of 90%.
- D. The client who is complaining about not receiving any pain medication.
Correct Answer: C
Rationale: A pulse oximetry of 90% (C) indicates hypoxemia, requiring immediate assessment to prevent respiratory compromise. Refusing turning (A), nausea (B), and pain complaints (D) are less urgent.
The public health nurse is discussing St. Louis encephalitis with a group in the community. Which instruction should the nurse provide to help prevent an outbreak?
- A. Yearly vaccinations for the disease.
- B. Advise that the city should spray for mosquitoes.
- C. The use of gloves when gardening.
- D. Not going out at night.
Correct Answer: B
Rationale: St. Louis encephalitis is mosquito-borne. Mosquito spraying (B) reduces vector populations. No vaccine exists (A), gloves (C) are irrelevant, and night avoidance (D) is less effective.
The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication?
- A. I will brush my teeth after every meal.'
- B. I will check my Dilantin level daily.'
- C. My urine will turn orange while on Dilantin.'
- D. I won’t have any seizures while on this medication.'
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene (A) is essential and indicates understanding. Dilantin levels (B) are checked periodically by providers, not daily. Urine color change (C) is not typical, and seizures may still occur (D) if not fully controlled.