Nokea
Which of the following describes a 'comfort zone'?
- A. The area where closeness is not required during nursing care.
- B. The area that encompasses up to 5 to 7 feet from the client.
- C. The area that,when intruded upon does not create any kind of anxiety.
- D. The area where a client is well draped.
Correct Answer: B
Rationale: A comfort zone typically refers to the personal space around an individual, which varies but generally extends up to 5-7 feet.
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In assigning patients with alterations related to gastrointestinal (GI) cancer, which would be the most appropriate nursing care tasks to assign to the LPN/LVN, under supervision of the team leader RN?
- A. A patient with severe anemia secondary to GI bleeding.
- B. A patient who needs enemas and antibiotics to control GI bacteria.
- C. A patient who needs pre-op teaching for bowel resection surgery.
- D. A patient who needs central line insertion for chemotherapy.
Correct Answer: B
Rationale: Administering enemas and antibiotics involves routine tasks that LPNs/LVNs are trained to perform, whereas the other options require advanced skills or supervision.
A student nurse arrives on the unit and asks you what the rationale for treatment of withdrawal is. What is the best response?
- A. To protect the patient while the body removes the drug from the patient's bloodstream.
- B. To protect the patient from relapsing during withdrawal.
- C. To treat the patient's psychological dependency on the substance.
- D. To treat the symptoms of withdrawal while the body removes the substance from the patient's bloodstream.
Correct Answer: D
Rationale: Treating withdrawal symptoms supports physiological stability as the body clears the substance.
What is contraindicated for a client being treated for Ménière’s disease?
- A. Alcohol
- B. Smoking
- C. A high-protein diet
- D. Cough syrups and other CNS depressants
Correct Answer: D
Rationale: CNS depressants can worsen dizziness and imbalance associated with Ménière’s disease.
What type of shock is the client experiencing if there is no urine return after inserting a Foley catheter?
- A. Decreased blood pressure
- B. Increased heart rate
- C. Fluid retention
- D. Muscle cramps
Correct Answer: A
Rationale: Decreased blood pressure is a primary symptom in fluid imbalance as a result of inadequate circulating volume, leading to hypotension and possible shock.
What is your priority intervention for this patient?
- A. Transportation arrangements to a safe house
- B. Referral to a counselor
- C. Advise about contacting the police
- D. Follow-up appointment for injuries
Correct Answer: A
Rationale: Ensuring the patient's safety by arranging transportation to a safe house is the top priority.