Nokea
Which plan best promotes a blind client's feeling of self-reliance when eating?
- A. Help the client locate food by comparing its placement to clock positions.
- B. Ask a hospital volunteer to feed the client so the client does not have to ask for help.
- C. Order foods that can be sipped from containers rather than eaten with utensils.
- D. Ask the dietary department to serve the client's food on paper plates and in cups.
Correct Answer: A
Rationale: Using clock positions empowers the client to eat independently by orienting them to food placement.
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The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included in the interventions?
- A. Use a pillow to keep the heels off the bed when supine.
- B. Order a low air-loss therapy bed immediately.
- C. Prepare to insert a nasogastric feeding tube.
- D. Order an occupational therapy consult for strength training.
Correct Answer: A
Rationale: Heel elevation prevents pressure ulcers in paralyzed clients. Low air-loss beds require HCP orders, NG tubes are premature, and OT is for rehabilitation, not immediate care.
When the nurse applies mafenide acetate cream to the burn wound, the nurse should recognize which of the following as its chief disadvantage?
- A. Skin discoloration
- B. Pain on application
- C. Unpleasant odor
- D. Contact dermatitis
Correct Answer: B
Rationale: Mafenide acetate causes significant pain upon application.
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider?
- A. The client is complaining of severe pain.
- B. The client’s pulse oximeter reading is 95%.
- C. The client has T 100.4°F, P 100, R 24, and BP 102/60.
- D. The client’s urinary output is 50 mL in two (2) hours.
Correct Answer: C
Rationale: Fever, tachycardia, and hypotension suggest sepsis or hypovolemia, requiring immediate HCP notification. Pain is expected, 95% SpO2 is acceptable, and low urine output is secondary.
The nurse is speaking with clients during a wellness fair. What information should the nurse provide to prevent or minimize burn injury? Select all that apply.
- A. Wear flame-retardant clothing, especially near flames.
- B. Use 'stop, drop, and roll' maneuvers if clothing is on fire.
- C. Burn candles that are placed only in glass containers.
- D. Put out a cooking fire by throwing salt on the fire.
- E. Install smoke detectors, including one by the furnace.
Correct Answer: A,B,E
Rationale: The nurse should discuss flame-retardant clothing. 'Stop, drop, and roll' maneuvers should be used to minimize burn. Smoke detectors should be included throughout the home, including one near the furnace. It does not matter what type of container holds the burning candle. For a small fire on the stove, covering the flame with a lid is recommended.
The nurse is preparing to irrigate the student's eye. What steps are appropriate in completing the irrigation? Select all that apply.
- A. The use the solution directly into the center of the eye.
- B. Tilt the head toward the opposite eye.
- C. Perform hand hygiene and put on gloves.
- D. Offer the client a paper tissue.
- E. Place the solution into the conjunctival sac.
- F. Continue eye irrigations until all redness is resolved.
Correct Answer: C,E
Rationale: Hand hygiene and gloves prevent infection, and placing the solution in the conjunctival sac ensures effective irrigation without damaging the cornea.