Nokea
You are serving as the supervisory nurse for a home healthcare agency in the community. You are doing an admission assessment for a 76 year old male client who resides with his elderly wife. Which of the following assessments would indicate that the couple needs some education relating to home safety?
- A. The client has refrigerated foods labelled with an expiration date.
- B. You assess that the home is free of scatter rugs that many use to protect the feet against hard floors.
- C. The client uses the FIFO method for insuring food safety.
- D. The client assures you that the smoke alarm batteries are replaced annually to insure that they work.
Correct Answer: B
Rationale: The absence of scatter rugs is a safety feature, not a concern requiring education. Labeled foods , FIFO method , and annual smoke alarm battery replacement are all safe practices. However, the question implies a need for education, and B is the least directly related to a safety deficit, but no clear safety issue is present in the options provided.
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A client with a diagnosis of diabetes insipidus asks the nurse about the purpose of the vasopressin she has been prescribed. The nurse responds, knowing that this medication promotes which action?
- A. Vasodilation
- B. Decrease in peristalsis
- C. Decrease in urinary output
- D. Inhibit smooth muscle contraction
Correct Answer: C
Rationale: Vasopressin is a vasopressor and an antidiuretic. It directly stimulates contraction of smooth muscle, causes vasoconstriction, stimulates peristalsis, and increases reabsorption of water by the renal tubules, resulting in decreased urinary output.
A client with metastatic cancer of the liver is concerned about his progress. Which of the following nursing interventions is most appropriate?
- A. Provide information for the client to consider a liver transplantation.
- B. Assure the client that the prescribed medications will shrink all tumor sites.
- C. Explain the effects of chemotherapy.
- D. Place emphasis on providing symptomatic and comfort measures.
Correct Answer: D
Rationale: For metastatic liver cancer, palliative care focusing on symptom relief and comfort is most appropriate, as transplantation or tumor shrinkage may not be feasible.
The nurse is teaching a client with a new diagnosis of epilepsy about medication adherence. Which of the following instructions is most important?
- A. Take the medication exactly as prescribed.
- B. Skip doses if you feel well.
- C. Double the dose if you miss one.
- D. Stop the medication if side effects occur.
Correct Answer: A
Rationale: Taking antiepileptic medication exactly as prescribed is critical to prevent seizures.
When giving a client a tube feeding the nurse should:
- A. Warm the feeding solution before administration.
- B. Place the client in a left side-lying position.
- C. Aspirate residual gastric contents before the feeding and discard.
- D. Verify position of the tube before beginning feeding.
Correct Answer: D
Rationale: Verifying tube position (e.g., via pH testing or X-ray) is critical to ensure safe administration and prevent aspiration.
A client has polycystic kidney disease. The client asks the nurse, 'How did I get these fluid-filled bubbles on my kidneys? I have not had any X-ray type tests.' How should the nurse respond to help the client understand risk factors for this disease process?
- A. Second-hand smoke puts you at greater risk for developing cysts.'
- B. Exposure to dyes used to color fruits and vegetables increases the risk of polycystic kidney disease.'
- C. There is a higher incidence of polycystic kidney disease among blood relatives.'
- D. Drinking alcohol daily allows the kidneys to develop cysts.'
Correct Answer: C
Rationale: Polycystic kidney disease is primarily genetic, with a higher incidence among blood relatives due to autosomal dominant or recessive inheritance patterns.