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A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?
- A. Suggest rinsing his mouth with an alcohol-based mouthwash
- B. Provide humidification of the room air
- C. Offer the client saltine crackers between meals
- D. Instruct the client on the use of esophageal speech
Correct Answer: B
Rationale: The correct answer is B: Provide humidification of the room air. Xerostomia is dry mouth often caused by radiation therapy, which can lead to discomfort and difficulty swallowing. Humidifying the room air can help alleviate dryness, making it easier for the client to breathe and swallow. Alcohol-based mouthwash (A) can worsen dryness due to its drying effect. Saltine crackers (C) can be difficult to swallow with a dry mouth. Esophageal speech (D) is not relevant to xerostomia.
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A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?
- A. Examine for leakage at the site of the procedure.
- B. Compare the client's current weight with preprocedure weight.
- C. Confirm that the client is able to urinate.
- D. Check the client's serum albumin levels.
Correct Answer: B
Rationale: The correct answer is B: Compare the client's current weight with preprocedure weight. This is because paracentesis is a procedure used to remove fluid buildup in the abdomen, which can lead to weight loss. By comparing the client's current weight with the preprocedure weight, the nurse can evaluate the effectiveness of the procedure in draining the excess fluid. This comparison helps determine the amount of fluid removed and assess the client's response to the treatment.
Explanations for why the other choices are incorrect:
A: Examining for leakage at the site of the procedure is important for monitoring for potential complications but does not directly evaluate the effectiveness of the procedure.
C: Confirming that the client is able to urinate is important for assessing kidney function but does not specifically evaluate the effectiveness of the paracentesis.
D: Checking the client's serum albumin levels may provide information about the client's liver function and nutritional status but does not directly evaluate the effectiveness of the paracentesis procedure.
A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?
- A. Remove the client's restraint every 4 hr.
- B. Document the client's condition every 15 min.
- C. Request a PRN restraint prescription for clients who are aggressive.
- D. Attach the restraint to the bed's side rail.
Correct Answer: B
Rationale: The correct answer is B: Document the client's condition every 15 min. This guideline is crucial to ensure the safety and well-being of the client in restraints. Documenting the client's condition frequently allows for timely identification of any signs of distress, discomfort, or complications related to the use of restraints. This practice helps in monitoring the client's physical and psychological status, enabling prompt intervention if necessary.
Removing the client's restraint every 4 hours (choice A) is incorrect as it may compromise the client's safety and increase the risk of injury or harm. Requesting a PRN restraint prescription for aggressive clients (choice C) is inappropriate as restraints should only be used as a last resort and not for convenience. Attaching the restraint to the bed's side rail (choice D) is unsafe and restricts the client's movement unnecessarily.
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
- A. Hypertension
- B. Fibromyalgia
- C. Renal calculi
- D. Fibrocystic breast disease.
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to combination oral contraceptive use due to the increased risk of cardiovascular events. The estrogen component in oral contraceptives can further elevate blood pressure, leading to complications. Other choices like B: Fibromyalgia, C: Renal calculi, and D: Fibrocystic breast disease are not contraindications for oral contraceptive use. Fibromyalgia is a chronic pain condition unrelated to oral contraceptives. Renal calculi are kidney stones, which do not directly affect the safety of oral contraceptives. Fibrocystic breast disease is a benign condition and not a contraindication to oral contraceptives.
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
- A. Check the client for injuries.
- B. Move hazardous objects away from the client.
- C. Notify the provider.
- D. Ask the client to describe how she felt prior to the fall.
Correct Answer: A
Rationale: The correct action is to check the client for injuries first because ensuring the client's immediate safety and well-being is the top priority. By assessing for injuries, the nurse can determine the severity of the situation and provide necessary interventions promptly. Moving hazardous objects (B) can wait until after ensuring the client's safety. Notifying the provider (C) can also be done after assessing the client's condition. Asking the client to describe how she felt prior to the fall (D) is important for gathering information but is not as urgent as checking for injuries.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Oliguria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, inflammation of the glomeruli causes blood to leak into the urine, resulting in hematuria. This is a classic sign of the condition. Oliguria (A) is decreased urine output, not typically associated with glomerulonephritis. Hypotension (B) is not a common finding as fluid retention is more likely. Weight loss (C) is not a typical symptom, as fluid retention and edema are more common. In summary, hematuria is the hallmark sign of acute glomerulonephritis, distinguishing it from the other choices.