Nokea
Which of the following interventions is most appropriate for a client who has stomatitis?
- A. Drinking hot tea at frequent intervals.
- B. Gargling with antiseptic mouthwash.
- C. Using an electric toothbrush.
- D. Eating a soft, bland diet.
Correct Answer: D
Rationale: Stomatitis involves inflammation of the oral mucosa, often causing pain and sensitivity. A soft, bland diet is most appropriate as it minimizes irritation and discomfort during eating. Hot tea, antiseptic mouthwash, and electric toothbrushes can exacerbate irritation or pain in the inflamed oral tissues.
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A 60-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following?
- A. Tachycardia.
- B. Weight gain.
- C. Diarrhea.
- D. Nausea.
Correct Answer: B
Rationale: Hypothyroidism causes a slowed metabolism, leading to weight gain. Tachycardia, diarrhea, and nausea are more associated with hyperthyroidism.
The nurse is planning care for a group of clients who have had total hip replacement. Of the clients listed below, which is at highest risk for infection and should be assessed first?
- A. A 55-year-old client who is 6 feet tall and weighs 180 lb.
- B. A 75-year-old who lives alone.
- C. A 74-year-old who has periodontal disease with periodontitis.
- D. A 75-year-old who has asthma and uses an inhaler.
Correct Answer: C
Rationale: Periodontal disease increases infection risk due to potential bacterial spread to the prosthesis.
The nurse is teaching a client about risk factors associated with atherosclerosis and how to reduce the risk. Which of the following is a risk factor that the client is not able to modify?
- A. Diabetes
- B. Age
- C. Exercise level
- D. Dietary preferences
Correct Answer: B
Rationale: Age is a non-modifiable risk factor for atherosclerosis, as the risk increases with advancing age due to cumulative vascular changes. Diabetes, exercise level, and dietary preferences can be managed or modified to reduce risk, making age the correct answer.
The following scenario applies to the next 1 items
The nurse has received prescriptions for a newborn infant in the postpartum unit.
Item 1 of 1
Orders
1958:
• phytonadione 1 mg intramuscular (IM) x 1 dose
• erythromycin ophthalmic ointment 0.5% apply from unit dose (1 cm) to both eyes
The nurse administers the prescribed medications.
The nurse should administer the phytonadione using ............ The nurse will inject the medication.............................It would be appropriate for the nurse to ...................... The nurse understands that the purpose of administering newborn erythromycin ophthalmic ointment is ............................. The nurse should apply this ointment to the ......................... Once the ointment is administered, the nurse should ..........................
- A. ¾-in, 25-gauge needle.
- B. into the middle third of the anterolateral aspect of the thigh.
- C. aspirate before injecting the medication.
- D. massage the area to promote medication absorption.
- E. prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae.
- F. lower conjunctival sac.
- G. wipe the ointment from the outer eye after one minute.
Correct Answer: A,B,D,E,F
Rationale: Phytonadione is administered with a 25-gauge, ¾-in needle in the vastus lateralis; erythromycin prevents ophthalmia neonatorum and is applied to the lower conjunctival sac without wiping.
At 8 a.m., the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should:
- A. Report the 24-hour drainage amount at 12. Clamp the T-tube.
- B. Evaluate the tube for patency.
- C. Irrigate the T-tube.
- D. Continue to monitor the drainage.
Correct Answer: C
Rationale: The T-tube should drain approximately 300 to 500 mL in the fi rst 24 hours and after 3 to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden decrease in drainage at 8 a.m., the nurse should immediately assess the tube for obstruction of flow that can be caused by kinks in the tube or the client lying on the tube. Drainage color must also be assessed for signs of bleeding. The tube should not be irrigated or clamped without an order.