Nokea
Which referral should the nurse implement for a client with severe multiple allergies?
- A. Registered dietitian.
- B. Occupational therapist.
- C. Recreational therapist.
- D. Social worker.
Correct Answer: A
Rationale: A dietitian helps identify food allergens, critical for severe allergies. Other therapists are less relevant.
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The client diagnosed with myasthenia gravis is admitted with an acute exacerbation. Which interventions should the nurse implement? Select all that apply.
- A. Assist the client to turn and cough every two (2) hours.
- B. Place the client in a high or semi-Fowler's position.
- C. Assess the client's pulse oximeter reading every shift.
- D. Plan meals to promote medication effectiveness.
- E. Monitor the client's serum anticholinesterase levels.
Correct Answer: A,B,C,D
Rationale: Turning/coughing, Fowler’s position, pulse oximetry, and meal timing address respiratory risk and medication efficacy in myasthenia gravis. Serum anticholinesterase levels are not routinely monitored.
The nurse is caring for a client with suspected fibromyalgia. Which diagnostic test confirms the diagnosis of fibromyalgia?
- A. There is no diagnostic test to confirm fibromyalgia.
- B. A positive antinuclear antibody test.
- C. A magnetic resonance imaging (MRI) shows fibrosis.
- D. A negative erythrocyte sedimentation rate (ESR).
Correct Answer: A
Rationale: Fibromyalgia is diagnosed clinically, with no confirmatory test. ANA, MRI, and ESR are not diagnostic.
The male client diagnosed with multiple sclerosis states he has been investigating alternative therapies to treat his disease. Which intervention is most appropriate by the nurse?
- A. Encourage the therapy if it is not contraindicated by the medical regimen.
- B. Tell the client only the health-care provider should discuss this with him.
- C. Ask how his significant other feels about this deviation from the medical regimen.
- D. Suggest the client research an investigational therapy instead.
Correct Answer: A
Rationale: Encouraging safe alternative therapies supports autonomy if they align with medical treatment. Deferring to HCP, involving significant other, or suggesting investigational therapies are less appropriate.
The nurse is developing a care plan for a client diagnosed with allergic rhinitis. Which independent problem has priority?
- A. Ineffective breathing pattern.
- B. Knowledge deficit.
- C. Anaphylaxis.
- D. Ineffective coping.
Correct Answer: A
Rationale: Ineffective breathing pattern is a priority in allergic rhinitis due to potential airway obstruction. Knowledge, anaphylaxis risk, and coping are secondary.
The charge nurse observes the primary nurse interacting with a client. Which action by the primary nurse warrants immediate intervention by the charge nurse?
- A. The nurse explains the IVP diuretic will make the client urinate.
- B. The nurse dons nonsterile gloves to remove the client's dressing.
- C. The nurse administers a medication without checking for allergies.
- D. The nurse asks the UAP for help moving a client up in bed.
Correct Answer: C
Rationale: Administering medication without checking allergies risks allergic reactions, requiring immediate intervention. Diuretic explanation, glove use, and UAP assistance are appropriate.