Nokea
A client with heart failure is being taught by a nurse on reducing daily sodium intake. What is the most important factor in determining the client's ability to learn new dietary habits?
- A. The involvement of the client in planning the change
- B. The presence of a dietitian during the teaching
- C. The use of dietary supplements
- D. The client's family support
Correct Answer: A
Rationale: The most crucial factor in the client's ability to learn new dietary habits is their involvement in planning the change. When clients actively participate in setting their dietary goals, they are more likely to commit to and adhere to the changes. This empowerment fosters a sense of ownership and responsibility, enhancing the chances of successful dietary modifications. The presence of a dietitian, use of dietary supplements, and family support, while beneficial, are not as critical as the client's active participation in planning the dietary changes.
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During a physical assessment, a nurse is assessing 4 adult clients. Which of the following physical assessment techniques should the nurse use?
- A. Ensure the bladder of the BP cuff surrounds 80% of their arm.
- B. Use the BP cuff on the forearm if the upper arm is not accessible.
- C. Apply the BP cuff loosely around the arm.
- D. Use a pediatric cuff for adults with small arms.
Correct Answer: A
Rationale: The correct answer is to ensure the bladder of the BP cuff surrounds 80% of the arm. This technique is crucial for obtaining accurate blood pressure readings. Choice B is incorrect because using the BP cuff on the forearm may lead to inaccurate readings. Choice C is incorrect as applying the BP cuff loosely can also result in inaccurate measurements. Choice D is incorrect because using a pediatric cuff for adults with small arms would not provide accurate blood pressure readings.
A child is injured on the school playground and appears to have a fractured leg. What action should the school nurse take first?
- A. Call for emergency transport to the hospital
- B. Immobilize the limb and joints above and below the injury
- C. Assess the child and the extent of the injury
- D. Apply cold compresses to the injured area
Correct Answer: C
Rationale: The correct first action for the school nurse to take when a child is injured and appears to have a fractured leg is to assess the child and the extent of the injury. This initial assessment is crucial to determine the severity of the injury before proceeding with further interventions. Option A, calling for emergency transport, should only be done after assessing the extent of the injury. Option B, immobilizing the limb and joints, is important but should come after the initial assessment. Option D, applying cold compresses, is not recommended for suspected fractures as it can exacerbate swelling and pain.
A nurse prepares an injection of morphine to administer to a client who reports pain but asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the second nurse take?
- A. Offer to assist the client who needs the bedpan.
- B. Administer the injection the other nurse prepared.
- C. Prepare another syringe and administer the injection.
- D. Tell the client who needs the bedpan to wait while the nurse gives someone else medication.
Correct Answer: C
Rationale: The second nurse should prepare a new syringe and administer the medication to ensure proper and timely pain management. Administering another nurse's medication without preparation could lead to errors. Choice A is not the priority as the medication administration should take precedence. Choice B is not recommended as the second nurse should not administer medication prepared by another nurse. Choice D is inappropriate as patient needs should not be compromised for medication administration to another client.
During an admission assessment for an older adult client, what is the priority action for the nurse after gathering data and reviewing systems?
- A. Orient the client to their room.
- B. Conduct a client care conference.
- C. Review medical prescriptions.
- D. Develop a plan of care.
Correct Answer: A
Rationale: The priority action for the nurse after completing the assessment and review of systems for an older adult client is to orient them to their room. This is crucial for ensuring the client's comfort and safety in the new environment. While reviewing medical prescriptions and developing a plan of care are important aspects of the admission process, they can be done after the client has been oriented to their room.
During a client admission, how should the nurse conduct medication reconciliation?
- A. Compare the client's home medications to the provider's prescriptions.
- B. Review the client's medical history.
- C. Assess the client's current medications.
- D. Ask the client about their allergies.
Correct Answer: A
Rationale: During medication reconciliation, the nurse should compare the client's home medications with the provider's prescriptions to ensure accuracy and prevent medication errors. Reviewing the client's medical history (Choice B) is important but not the primary focus of medication reconciliation. Assessing the client's current medications (Choice C) is also vital but is not specific to the comparison between home and prescribed medications during reconciliation. Asking the client about their allergies (Choice D) is relevant for ensuring safe medication administration but is not the primary step in medication reconciliation, which involves comparing actual medications.