Nokea
Before digital removal of a fecal impaction, which type of enema should the nurse give to loosen the feces?
- A. Oil Retention
- B. Saline
- C. Soapy Water
- D. Hypertonic
Correct Answer: A
Rationale: An oil retention enema containing mineral oil is the most suitable choice to help soften and loosen a fecal impaction before digital removal. Mineral oil lubricates and softens the stool, facilitating passage. Saline enemas draw water into the colon to promote bowel movements but may not effectively soften a fecal impaction. Soapy water enemas are primarily for cleansing, not softening stool. Hypertonic enemas eliminate fluid from the body and are not appropriate for loosening fecal impactions.
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A client is scheduled for a bronchoscopy. After the nurse explains the procedure, which statement by the client indicates a need for further teaching?
- A. I'm glad I don't have to lie still for this procedure.
- B. I will have a local anesthetic to help with discomfort.
- C. I hope I get some medicine to relax me.
- D. I can't eat or drink for 6 hours before the procedure.
Correct Answer: A
Rationale: The correct answer is A because the client's statement indicates a misunderstanding about the need to lie still during the bronchoscopy procedure. The client actually needs to remain still for the procedure to ensure its accuracy and safety. Choices B, C, and D demonstrate an understanding of the procedure by acknowledging the local anesthetic for discomfort, the possibility of receiving medicine for relaxation, and the requirement to fast before the procedure, respectively.
The nurse is providing education about the importance of proper foot care to a patient diagnosed with diabetes mellitus. Which primary goal is the nurse trying to achieve?
- A. Prevention of plantar warts
- B. Prevention of foot fungus
- C. Prevention of neuropathy
- D. Prevention of amputation
Correct Answer: D
Rationale: The correct answer is D: Prevention of amputation. Patients with diabetes are at a higher risk of foot complications, such as ulcers, infections, and ultimately, amputations. Proper foot care education aims to prevent these serious complications. Choices A, B, and C are incorrect because while they are also important aspects of foot care, the primary goal in diabetes management is to prevent severe outcomes like amputation.
An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care?
- A. Irrigate the affected area with running water.
- B. Wash the affected area with antibacterial soap.
- C. Brush the chemical off the skin and clothing.
- D. Leave the clothing in place until emergency personnel arrive.
Correct Answer: C
Rationale: The correct intervention for an employee exposed to an unknown dry chemical is to brush off the chemical from the skin and clothing. This helps prevent further skin contact before irrigation can be done. Irrigating the affected area with running water is crucial after brushing off the chemical to minimize the exposure. Washing the affected area with antibacterial soap is not appropriate for chemical burns, as soap can react with certain chemicals and worsen the situation. Leaving the clothing in place until emergency personnel arrive may allow the chemical to continue to harm the skin and should be avoided.
A caregiver of an immobile client requiring assistance with repositioning is being taught by a nurse on preventing back strain. Which statement by the caregiver indicates an understanding of the teaching?
- A. I will place the bed in the lowest position
- B. I will tighten my abdominal muscles prior to moving
- C. I will keep my legs straight to provide more power in the lift
- D. I will twist at the waist while pulling the draw sheet
Correct Answer: B
Rationale: The correct answer is B. Tightening the abdominal muscles before moving helps protect the back by providing core support. Keeping the legs straight (choice C) is incorrect as bending the legs is recommended to provide a stable base and prevent strain on the back. Twisting at the waist (choice D) while moving can cause back injury due to the strain on the spine. Placing the bed in the lowest position (choice A) is not directly related to preventing back strain during client repositioning, although it may be necessary for other reasons.
A healthcare professional is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the healthcare professional take next?
- A. Assess the client for orthostatic hypotension
- B. Obtain a gait belt
- C. Ensure the client has proper footwear
- D. Ask the client to perform range-of-motion exercises
Correct Answer: A
Rationale: Assessing the client for orthostatic hypotension is the priority before transferring a client who can bear weight on one leg. This assessment helps identify the risk of dizziness or fainting when the client moves from a supine to an upright position. Obtaining a gait belt may be necessary for the transfer, but assessing for orthostatic hypotension comes first to ensure the safety of the client. Ensuring the client has proper footwear is important for preventing falls during ambulation but is not the immediate next step in this situation. Asking the client to perform range-of-motion exercises is not necessary before the transfer and does not address the immediate safety concern of orthostatic hypotension.