Nokea
The nurse is teaching a client how to perform self-monitoring blood glucose (SMBG) using a blood glucose monitor.
Which of the following actions, if performed by the client, indicates to the nurse the need for further teaching?
- A. The client lets her hand dangle before sticking her finger with the lancet.
- B. The client sticks her finger on the side of the distal phalanx.
- C. The client touches the strip with a large drop of blood hanging from her fingertip.
- D. The client milks her finger after sticking it.
Correct Answer: D
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) helps to facilitate venous congestion (2) less painful than the center of the fingertip (3) blood should sit on the strip like a raindrop, smearing alters the reading (4) correct-forces interstitial fluid to mix with capillary blood and dilutes the blood
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A 21-year-old woman at 16 -weeks gestation undergoes an amniocentesis. The client asks the nurse what the physician will learn from this procedure. The nurse's response should be based on an understanding that which of the following conditions can be detected by this Test ?
- A. Tetralogy of Fallot.
- B. Talipes equinovarus.
- C. Hemolytic disease of the newborn.
- D. Cleft lip and palate.
Correct Answer: C
Rationale: maternal antibodies destroy fetal RBCs; bilirubin secreted because of hemolysis
The nurse is caring for a client with a history of glaucoma.
- A. Which instruction should the nurse include for a client with glaucoma using timolol eye drops?
- B. Apply pressure to the inner canthus after instillation.
- C. Administer the drops at bedtime only.
- D. Use the drops only when symptoms occur.
- E. Cleanse the eye with saline before instillation.
Correct Answer: A
Rationale: Applying pressure to the inner canthus (nasolacrimal occlusion) prevents systemic absorption of timolol, reducing side effects like bradycardia. Drops are used regularly, not symptom-based, and cleansing is unnecessary unless debris is present.
The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which other finding is most likely to occur?
- A. Chest pain
- B. Peripheral edema
- C. Nail clubbing
- D. Lethargy
Correct Answer: B
Rationale: Peripheral edema. Bibasilar crackles and peripheral edema are common in congestive heart failure due to fluid overload.
A three-year-old boy was shown to have delays on the Denver Development Screening Test (DDST).
Which of the following responses by the nurse is BEST?
- A. Maybe he is just having a bad day. I'm sure he will do much better next time.
- B. The Test indicated a delay and we will have to investigate to learn more.
- C. What are your thoughts about how your child performed on the Test ?
- D. The results may not be accurate. Let's set up a time to reTest your child.
Correct Answer: C
Rationale: Strategy: 'BEST' indicates that fine discrimination is required. The topic of the questions is unstated. Determine topic by reading the answer choices. (1) nontherapeutic, false reassurance (2) factual but closed communication (3) correct-open-ended, encourages discussion (4) doesn't encourage discussion of concerns
A client arrives in the emergency department after a radiologic accident at a local factory. The first action of the nurse would be to
- A. begin decontamination procedures for the client
- B. ensure physiologic stability of the client
- C. wrap the client in blankets to minimize staff contamination
- D. double bag the client's contaminated clothing
Correct Answer: B
Rationale: The nurse must initially assist in stabilizing the patient prior to performing the other tasks related to radiologic contamination.