Nokea
While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?
- A. Unpleasant odor of the breath
- B. White patches on the mucosa.
- C. Gumline that has visibly receded.
- D. Discoloration of several teeth.
Correct Answer: B
Rationale: White patches suggest thrush requiring treatment.
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The nurse retrieves hydromorphone '4 mg/mL' from the electronic medication system, for a patient who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the nurse administer to the patient? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 0.8
Rationale: 3 mg ÷ 4 mg/mL = 0.75 mL, rounded to 0.8 mL.
The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?
- A. Print the electronic medical record (EMR) from a backup server.
- B. Identify information as a late entry in the record.
- C. Wait for notification that the system has been rebooted.
- D. Notify the information services department of the situation.
Correct Answer: D
Rationale: Notifying IT resolves system issues promptly.
The nurse is providing postoperative teaching to a client on ways to prevent constipation. Which information should the nurse include?
- A. Drink 800 to 1,000 milliliters of fluid daily.
- B. Take oxycodone as scheduled to prevent painful bowel movements.
- C. Add fat-containing foods in the diet to lubricate stools for easier passage.
- D. Ambulate early and as frequently as possible.
Correct Answer: D
Rationale: Ambulation stimulates bowel function.
An unlicensed assistive personnel (UAP) assigned to feed a client with meningococcal infection, for whom droplet precautions have been implemented, requests a change in assignment, reporting they have not yet been fitted for an N95 respirator mask. Which action should the nurse take?
- A. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care.
- B. Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client.
- C. Before changing assignments, determine which staff members have fitted particulate filter masks.
- D. Send the UAP to be fitted for a particulate filter mask immediately to be able to provide care to this client.
Correct Answer: B
Rationale: Standard mask suffices for droplet precautions.
After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?
- A. Discontinue the use of the nasal cannula.
- B. Apply lubricant to the cannula tubing.
- C. Place padding around the cannula tubing.
- D. Decrease the flow rate to 1 L/minute.
Correct Answer: C
Rationale: Padding prevents skin breakdown.