Nokea
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?
- A. Have the client hold his breath briefly
- B. Discontinue the fluid instillation
- C. Remind the client that cramping is common at this time
- D. Lower the enema fluid container
Correct Answer: D
Rationale: The correct answer is D: Lower the enema fluid container. This intervention helps slow down the flow of the enema solution, reducing the client's discomfort from cramping. By lowering the container, the rate of fluid instillation decreases, giving the client's body more time to adjust to the enema. This action promotes better tolerance and helps alleviate abdominal cramping.
Other choices are incorrect:
A: Having the client hold his breath briefly does not address the underlying cause of the cramping and may increase discomfort.
B: Discontinuing the fluid instillation abruptly can cause incomplete cleansing and may not address the cramping effectively.
C: Merely reminding the client that cramping is common does not provide immediate relief or help manage the discomfort.
By choosing option D, the nurse can effectively manage the client's cramping during the enema procedure.
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A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? Select all.
- A. Apply the oxygen source loosely if the SPO2 decreases during the procedure
- B. Use surgical asepsis to remove & clean the inner cannula
- C. Clean the outer surfaces in a circular motion from the stoma site outward
- D. Replace the tracheostomy ties with new ties
- E. Cut a slit in gauze squares to place beneath the tube holder
Correct Answer: A, B, C
Rationale: The correct actions are A, B, and C. A) Applying the oxygen source loosely if the SPO2 decreases during the procedure ensures adequate oxygenation. B) Using surgical asepsis to remove and clean the inner cannula prevents infection. C) Cleaning the outer surfaces in a circular motion from the stoma site outward helps prevent contamination. Other options are incorrect because: D) Replacing the tracheostomy ties with new ties is not necessary each time. E) Cutting a slit in gauze squares is not a standard practice for tracheostomy care.
A nurse is caring for a client diagnosed w/severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable & infectious diseases. Which of the following illustrate the rationale for reporting? Select all.
- A. Planning & evaluating control & prevention strategies
- B. Determining public health priorities
- C. Ensuring proper medical treatment
- D. Identifying endemic disease
- E. Monitoring for common-source outbreaks
Correct Answer: A, B, C, E
Rationale: The correct answers are A, B, C, and E. Reporting communicable diseases like SARS is crucial for planning and evaluating control and prevention strategies. It helps in determining public health priorities by identifying trends and areas that require attention. Reporting ensures proper medical treatment for the affected individuals and their contacts, preventing further spread. Additionally, monitoring for common-source outbreaks allows for timely intervention to limit the spread of the disease. Choices D, F, and G are incorrect as they do not directly relate to the rationale for reporting communicable diseases in this context.
A nurse is caring for a client who has been sitting in a chair for 3 hours. Which of the following problems is the client at risk for developing?
- A. Stasis of secretions
- B. Muscle atrophy
- C. Pressure ulcer
- D. Fecal impaction
Correct Answer: C
Rationale: The correct answer is C: Pressure ulcer. Prolonged sitting can lead to decreased blood flow to tissues, causing pressure ulcers. Stasis of secretions (A) is more related to respiratory issues. Muscle atrophy (B) is a result of inactivity but not typically seen after only 3 hours. Fecal impaction (D) is more related to constipation, not prolonged sitting.
A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray?
- A. Cooked barley
- B. Pureed broccoli
- C. Vanilla custard
- D. Lentil soup
Correct Answer: C
Rationale: The correct answer is C: Vanilla custard. A low-residue diet aims to minimize fiber intake to reduce the bulk and frequency of bowel movements. Vanilla custard is low in fiber, making it suitable for this diet. Cooked barley (A) and lentil soup (D) are high in fiber and not recommended. Pureed broccoli (B) contains fiber and should be avoided. In summary, vanilla custard is the best choice for a low-residue diet due to its low fiber content compared to the other options.
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take next?
- A. Request a prescription for an antihypertensive medication
- B. Ask the client if she is having pain
- C. Request a prescription for an anti-anxiety medication
- D. Return in 30 minutes to recheck the client's BP
Correct Answer: B
Rationale: The correct answer is B. When a client with a fractured femur presents with an elevated blood pressure reading, it is important for the nurse to first assess if the client is in pain. Pain can cause an increase in blood pressure due to stress and sympathetic nervous system activation. Addressing pain management is crucial to providing holistic care and may help lower the blood pressure without the need for antihypertensive medications. Requesting an antihypertensive medication (choice A) without addressing the potential pain issue would not be appropriate at this time. Similarly, requesting an anti-anxiety medication (choice C) without further assessment would not address the underlying cause of the elevated blood pressure. Returning in 30 minutes to recheck the client's BP (choice D) is not as proactive as addressing the potential pain issue immediately.