Nokea
Which of the following is an appropriate action by the nurse?
- A. Suggest rinsing his mouth with an alcohol-based mouth wash
- B. Provide humidification of the room air.
- C. Offer the client saltine crackers between meals
- D. Instruct the client on the use of esophageal speech
Correct Answer: B
Rationale: The correct answer is B: Provide humidification of the room air. Humidification helps to moisturize the air, making it easier for the client to breathe, especially if they have dry mouth or throat. This can improve comfort and prevent irritation. Choice A is incorrect because alcohol-based mouthwash can further dry out the mouth. Choice C is incorrect as saltine crackers can exacerbate dry mouth. Choice D is incorrect as esophageal speech is not related to addressing dry mouth.
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Which of the following should the nurse use to access the port?
- A. An angiocatheter
- B. A 25-gauge needle
- C. A butterfly needle
- D. A noncoring needle
Correct Answer: D
Rationale: The correct answer is D: A noncoring needle. The nurse should use a noncoring needle to access the port because it is specifically designed for this purpose. Noncoring needles have a special tip that minimizes damage to the port septum, reducing the risk of complications such as infection or port damage. An angiocatheter (A) is not ideal for accessing a port as it is designed for venipuncture, not for accessing ports. A 25-gauge needle (B) may be too small and may not provide adequate flow. A butterfly needle (C) is not recommended for accessing ports due to its design and potential for septum damage.
Complete the following sentence by using the list of options. The client is at risk of----- as evidenced by-------
- A. fluid volume overload
- B. anemia
- C. hypostatic pneumonia
- D. calorie deficiency
- E. orthostatic hypotension
- F. immobility
Correct Answer: C,F
Rationale: Immobility increases the risk of hypostatic pneumonia, especially in clients with paraplegia.
For each assessment finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock.
- A. Hypercapnia
- B. Muscle rigidity
- C. Tachycardia
- D. Urticaria
- E. Wheezes
Correct Answer:
Rationale: Rationales provided within the question context.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
- A. Remove the cap and place it stenile-side up on a clean surface.
- B. Place sterile gauze over areas of spilled solution within the sterile field.
- C. Hold the bottle in the center of the sterile field when pouring the solution.
- D. Hold the irrigation solution bottle with the label facing away from the palm of the hand
Correct Answer: A
Rationale: The correct answer is A. When setting up a sterile field, it is essential to maintain sterility. By removing the cap and placing it sterile-side up on a clean surface, the nurse ensures that the inside of the cap, which will come into contact with the sterile solution, remains uncontaminated. Placing the cap sterile-side up prevents any potential contaminants from coming into contact with the solution. This practice follows aseptic technique guidelines to prevent the introduction of pathogens.
Choices B, C, and D are incorrect because they do not address the key principle of maintaining sterility. Placing sterile gauze over spilled solution (B) can introduce contaminants to the field, holding the bottle in the center (C) does not prevent contamination, and the orientation of the label (D) does not affect sterility.
Which of the following instructions should the nurse include?
- A. Monitor for weight loss
- B. Increase dietary calcium.
- C. Take on an empty stomach.
- D. Schedule dosage at bedtime
Correct Answer: B
Rationale: The correct answer is B: Increase dietary calcium. This instruction is important for a patient likely prescribed with a medication that can deplete calcium levels. Calcium is essential for bone health and overall well-being. Monitoring weight loss (A) is important but not directly related to the medication's side effects. Taking on an empty stomach (C) or at bedtime (D) may be specific to certain medications, but not universally applicable.