Nokea
Which of the following is most effective in assessing the client suspected of developing diabetes insipidus?
- A. Taking vital signs every 2 hours.
- B. Measuring urine output hourly.
- C. Assessing arterial blood gas values every other day.
- D. Checking blood glucose levels.
Correct Answer: B
Rationale: Diabetes insipidus, often caused by head injury, leads to excessive dilute urine output. Hourly urine output measurement is the most effective way to detect this condition early. Vital signs, blood gases, and glucose levels are less specific for this diagnosis.
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A client with leukemia is admitted with a white blood cell count of 2,000/mm³ and a fever of 101.8°F (38.8°C). The nurse should initiate:
- A. Contact precautions.
- B. Reverse isolation.
- C. Standard precautions.
- D. Droplet precautions.
Correct Answer: B
Rationale: A low white blood cell count (2,000/mm³) with fever indicates neutropenia and high infection risk, necessitating reverse isolation to protect the client from pathogens.
After teaching the client with a femoral fracture about the purpose of treatment with skeletal traction, which of the following, if stated by the client, would indicate the need for additional teaching?
- A. To align injured bones.
- B. To provide long-term pull.
- C. To apply 25 lb of traction.
- D. To pull weight with a boot.
Correct Answer: C
Rationale: The amount of traction (e.g., 25 lb) is specific to the injury and not a general purpose, indicating a misunderstanding.
The nurse instructs the unlicensed nursing personnel (UAP) on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the UAP to incorporate into the client's daily care?
- A. Assess the oral cavity each time mouth care is given and record observations.
- B. Use a soft toothbrush to brush the client's teeth after each meal.
- C. Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours.
- D. Rinse the client's mouth with mouthwash several times a day.
Correct Answer: B
Rationale: Using a soft toothbrush after meals is an effective and safe method for providing oral hygiene, promoting cleanliness without causing trauma.
If a client is receiving rescue breaths and the chest wall fails to rise during cardiopulmonary resuscitation, the rescuer should first:
- A. Try using an ambu bag.
- B. Decrease the rate of compressions.
- C. Intubate the client.
- D. Reposition the airway.
Correct Answer: D
Rationale: Failure of the chest to rise during rescue breaths suggests airway obstruction or improper positioning. Repositioning the airway (e.g., head-tilt-chin-lift) is the first step.
The nurse is to administer an antibiotic to a client with burns now, but there is no medication in the client's medication box. What should the nurse do first?
- A. Inform the unit's shift coordinator.
- B. Contact the client's physician.
- C. Call the pharmacy department.
- D. Borrow the medication from another client.
Correct Answer: C
Rationale: Calling the pharmacy ensures timely delivery of the correct medication, maintaining safety and adherence to protocol. Borrowing medication is unsafe and unethical.