A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?
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Solution
Answer A is correct. The client with unilateral neglect will neglect one side of the body. Answers B, C, and D are not associated with unilateral neglect.
A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should:
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Solution
Answer D is correct. Because the client is immune-suppressed, foods should be served in sealed containers, to avoid food contaminants. Answer B is incorrect because of possible infection from visitors. Answer A is not necessary, but the utensils should be cleaned thoroughly and rinsed in hot water. Answer C might be a good idea, but alcohol can be drying and can cause the skin to break down.
A new nursing graduate indicates in charting entries that he is a licensed practical nurse, although he has not yet received the results of the licensing exam. The graduate’s action can result in what type of charge:
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Solution
Answer A is correct. Identifying oneself as a nurse without a license defrauds the public and can be prosecuted. A tort is a wrongful act; malpractice is failing to act appropriately as a nurse or acting in a way that harm comes to the client; and negligence is failing to perform care. Therefore, answers B, C, and D are incorrect.
The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant?
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Solution
Answer B is correct. The client with the appendectomy is the most stable of these clients and can be assigned to a nursing assistant. The client with bronchiolitis has an alteration in the airway, the client with periorbital cellulitis has an infection, and the client with a fracture might be an abused child. Therefore, answers A, C, and D are incorrect.
During the change of shift, the oncoming nurse notes a discrepancy in the number of Percocet (Oxycodone) listed and the numberpresent in the narcotic drawer. The nurse’s first action should be to:
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Solution
Answer B is correct. The first action the nurse should take is to report the finding to the nurse supervisor and follow the chain of command. If it is found that the pharmacy is in error, it should be notified, as stated in answer A. Answers C and D, notifying the director of nursing and the Board of Nursing, might be necessary if theft is found, but not as a first step; thus, these are incorrect answers.
Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit?
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Solution
Answer B is correct. The best client to transport to the postpartum unit is the 40-yearold female with a hysterectomy. The nurses on the postpartum unit will be aware of normal amounts of bleeding and will be equipped to care for this client. The clients in answers A and D will be best cared for on a medical-surgical unit. The client with depression in answer C should be transported to the psychiatric unit.
A client with glomerulonephritis is placed on a low-sodium diet. Which of the following snacks is suitable for the client with sodium restriction?
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Solution
Answer D is correct. The fresh peach is the lowest in sodium of these choices. Answers A, B, and C have much higher amounts of sodium.
A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?
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Solution
Answer B is correct. The client with congestive heart failure who is complaining of nighttime dyspnea should be seen first because airway is no. 1 in nursing care. In answers A, C, and D, the clients are more stable.
A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by:
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Solution
Answer D is correct. Xerostomia is dry mouth, and offering the client a saliva substitute will help the most. Eating hard candy in answer A can further irritate the mucosa and cut the tongue and lips. Administering an analgesic might not be necessary; thus,answer B is incorrect. Splinting swollen joints, in answer C, is not associated with xerostomia.
The nurse is making assignments for the day. Which client should be assigned to the nursing assistant?
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Solution
Answer A is correct. The client with Alzheimer’s disease is the most stable of these clients and can be assigned to the nursing assistant, who can perform duties such as feeding and assisting the client with activities of daily living. The clients in answers B, C, and D are less stable and should be attended by a registered nurse.