Nokea
Which of the following is the priority nursing diagnosis?
- A. Risk for Infection related to organisms specific to cat bites
- B. Impaired Skin Integrity related to puncture wounds
- C. Ineffective Health Maintenance related to immunization status
- D. Risk for Impaired Mobility related to potential tendon damage
Correct Answer: A
Rationale: Cat bites carry a high risk of infection due to the bacteria present in their mouths.
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A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by hemodialysis?
- A. Low hemoglobin.
- B. Hypernatremia.
- C. High serum creatinine.
- D. Hyperkalemia.
Correct Answer: A
Rationale: Hemodialysis does not directly improve anemia caused by low hemoglobin.
The charge nurse assigned the care of a client with acute renal failure and hypernatremia to you, a newly graduated RN. Which actions can you delegate to the nursing assistant? (Choose all that apply.)
- A. Provide oral care every 3-4 hours
- B. Monitor for indications of dehydration
- C. Administer 0.45% saline by IV line
- D. Assess daily weights for trends
Correct Answer: A
Rationale: Oral care and assessing daily weights are tasks that can be delegated to a nursing assistant. Monitoring for dehydration and administering IV fluids require more advanced clinical skills.
Which of the following describes task-oriented touch?
- A. It is used to demonstrate concern or affection.
- B. It involves the contact required for nursing procedures.
- C. The nurse uses task-oriented touch therapeutically when a client is lonesome.
- D. It involves the touch used for sensory-deprived clients.
Correct Answer: B
Rationale: Task-oriented touch is necessary for performing nursing procedures and ensuring client safety.
Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called:
- A. Craving.
- B. Crashing.
- C. Outward bound.
- D. Nodding out.
Correct Answer: B
Rationale: Crashing refers to the intense fatigue and depression following cocaine use.
Mary, who is scheduled for a thoracentesis, asks why there is so much fluid in the pleural space. You respond by saying
- A. Your body is unable to remove fluid, resulting in a buildup of fluid in the pleural space around your lungs.
- B. An error occurred and you were administered too much IV medication.
- C. This is the result of oxygen therapy.
- D. This is a normal side effect of bumetanide, which is medication ordered by your physician.
Correct Answer: A
Rationale: Fluid accumulation in the pleural space can occur due to various conditions like heart failure or infection.