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Which task should be assigned to the nursing assistant?
- A. Placing the client in seclusion
- B. Emptying the Foley catheter of the preeclamptic client
- C. Feeding the client with dementia
- D. Ambulating the client with a fractured hip
Correct Answer: C
Rationale: Feeding a client with dementia is within the nursing assistant's scope, as it involves basic care and does not require advanced skills.
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The doctor has ordered a patient-controlled analgesia (PCA) pump for the client with chronic pain. The client asks the nurse if he can become overdosed with pain medication using this machine. The nurse demonstrates understanding of the PCA if she states:
- A. The machine will administer only the amount that you need to control your pain without any action from you.'
- B. The machine has a locking device that prevents overdosing.'
- C. The machine will administer one large dose every 4 hours to relieve your pain.'
- D. The machine is set to deliver medication only if you need it.'
Correct Answer: B
Rationale: The PCA pump has a lockout mechanism to prevent overdosing, ensuring safe, patient-controlled dosing.
The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:
- A. Grimacing and writhing movements decrease with relaxation and rest.
- B. Hypoactive deep tendon reflexes become more active with rest.
- C. Stretch reflexes are increased with rest.
- D. Fine motor movements are improved by rest.
Correct Answer: A
Rationale: Rest reduces spasticity and involuntary movements in cerebral palsy.
The nurse is caring for a client who abuses narcotics. The client is exhibiting a respiratory rate of 10 and dilated pupils. Which drug would the nurse expect to administer?
- A. Meperidine (Demerol)
- B. Naloxone (Narcan)
- C. Chlordiazepoxide (Librium)
- D. Haloperidol (Haldol)
Correct Answer: B
Rationale: Respiratory depression (rate of 10) and dilated pupils suggest opioid overdose. Naloxone (Narcan) is the antidote to reverse opioid toxicity.
All of the following statements regarding scarlet fever are true EXCEPT
- A. rheumatic fever is a possible complication of scarlet fever.
- B. scarlet fever can be treated with antibiotics.
- C. a vaccine is available to protect against scarlet fever.
- D. scarlet fever is caused by an erythrogenic toxin.
Correct Answer: C
Rationale: No vaccine exists for scarlet fever, which is caused by Streptococcus pyogenes’ erythrogenic toxin and treated with antibiotics. Rheumatic fever is a complication.
The nurse is caring for a 16-year-old female with second- and third-degree burns to the face, neck, chest, and arms. The client's wounds are almost healed. The nurse would expect rehabilitation to focus on problems related to:
- A. Body image disturbance
- B. Risk for infection
- C. Sensory perceptual alterations
- D. Activity intolerance
Correct Answer: A
Rationale: Burns to visible areas like the face and neck can significantly impact body image, especially in a teenager, making this a priority during rehabilitation as wounds heal.