Nokea
While performing care for a 72-year-old woman, the nurse notices that the patient has a dry, parched mouth and tongue. The nurse should
- A. brush the patient's teeth with a hard-bristled toothbrush before meals and at bedtime.
- B. use glycerin swabs to perform mouth care every 4 hours.
- C. rinse the patient's mouth with room-temperature tap water before and after meals.
- D. use a water pick, then rinse with commercial mouthwash every 8 hours to freshen the mouth.
Correct Answer: C
Rationale: will hydrate the mucous membranes and keep mouth clean
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A client is admitted to the unit with pregnancy-induced hypertension (PIH).
Which of the following actions is the priority nursing action?
- A. Start an IV.
- B. Obtain the vital signs.
- C. Administer magnesium sulfate.
- D. Notify the lab to draw blood.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) implementation, not a priority action (2) correct-assessment, important to do a baseline assessment in order to successfully evaluate the treatment (3) implementation, not a priority action (4) implementation, not a priority action
A 68-year-old woman comes to the outpatient clinic for a routine health screening. The nurse learns the client is a retired teacher who lives alone on a limited income. A history indicates the client drinks about 1,500 cc a day and her diet consists primarily of starches. It is MOST important for the nurse to encourage the client to
- A. increase her intake of protein.
- B. increase her intake of vitamins.
- C. reduce her caloric intake.
- D. reduce her fluid intake.
Correct Answer: A
Rationale: protein needed to slow down degeneration process of aging
The nurse is caring for a schizophrenic client who has become increasingly withdrawn to the point of mutism. The MOST important nursing approach at this time would be to
- A. ignore the client until he is ready to respond.
- B. sit with the client for brief periods of time.
- C. read to the client in a quiet area of the unit.
- D. encourage the client to play dominos with the group.
Correct Answer: B
Rationale: nurse should maintain contact with client but not make demands to communicate or participate in activities
The home care nurse instructs the wife of a client about how to perform a wet-to-dry abdominal dressing for her husband with an infected abdominal incision. The nurse should intervene in which of the following situations?
- A. The wife wets the old dressing with sterile saline before removing it.
- B. The wife covers the wound with wet, sterile 4 × 4s.
- C. The wife irrigates the wound with hydrogen peroxide using a bulb syringe.
- D. The wife uses Montgomery straps to secure the dressing.
Correct Answer: A
Rationale: contraindicated, remove dry so wound debris and necrotic tissue are removed with old dressing
A client is transferred to the neurology unit after developing right-sided paralysis and aphasia. Which of the following should be included in the patient's plan of care?
- A. Encourage client to shake head in response to questions.
- B. Speak in a loud voice during interactions.
- C. Speak using phrases and short sentences.
- D. Encourage the use of radio to stimulate the client.
Correct Answer: C
Rationale: will decrease tension and anxiety; client may understand some of the incoming communication if it is kept simple; speech may be relearned with appropriate support and interventions