Nokea
Mr. H. is upset regarding being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except:
- A. the right to examine and question the bill
- B. the right to reasonable response to requests
- C. the right to refuse treatment
- D. the right to confidentiality
Correct Answer: D
Rationale: The client's concern about costs suggests he may demand to examine the bill, expect reasonable responses, or refuse treatment. Confidentiality, while a right, is unrelated to his stated financial concerns and is not suggested to be breached.
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The experienced nurse observes the student nurse caring for the client with the wet plaster cast illustrated. Which conclusion by the experienced nurse is correct?
- A. The student should not be touching the plaster cast because it is wet.
- B. The student should be using a pillow to lift the client's casted extremity.
- C. The student is correctly handling a wet plaster cast with the palms.
- D. The student should be using fingers and not the palms to handle the cast.
Correct Answer: C
Rationale: C: Using palms prevents indentations in wet casts. A: Wet casts can be touched to reposition. B: Pillows limit inspection of the cast underside. D: Fingers cause pressure points.
Which of the following statements to the client's family would be appropriate when preparing to provide postmortem care to the client?
- A. You will not be allowed to see your family member after the post-mortem care is performed.
- B. I am not able to assist you, but we can call pastoral care if you need any comfort.
- C. Unfortunately, we are not allowed to incorporate any cultural practices in my preparations.
- D. I will be ensuring that your family member is properly identified before they are transported.
Correct Answer: D
Rationale: When providing post-mortem care, ensure the patient is properly identified and labeled before transporting. If possible, cultural practices should be incorporated, and the family should be allowed to see the client. When possible, the nurse should provide comfort to the family.
A hospitalized adult client who routinely works from midnight until 8 a.m. has a temperature of 99.1°F at 4 a.m. The nurse determines that this is most likely due to:
- A. delta sleep
- B. slow brain waves
- C. pneumonia
- D. circadian rhythm
Correct Answer: D
Rationale: Biological rhythms that follow a cycle lasting about 24 hours are termed circadian rhythm. The sleep-wake cycle is closely linked with cardiac rhythms, such as body temperature. While a person sleeps, core body temperature drops, often reaching the 24-hour low at 4 a.m. When the sleep period shifts, temperature fluctuations also shift to match the new sleep patterns.
A standard walker is used when clients:
- A. have poor balance, cannot stand up, have weak arms, and have good hand strength.
- B. have poor balance, have a broken leg, or have experienced amputation.
- C. have poor balance, have cardiac problems, or cannot use crutches or a cane.
- D. have poor balance, have an autoimmune disease, or have weak arms.
Correct Answer: C
Rationale: A walker is used for clients who have balance problems, cardiac problems, or cannot use crutches or a cane. The client needs to bear partial weight and have strength in her wrists and arms. The client uses her upper body to propel the walker forward.
When making an occupied bed, it is important for the nurse to:
- A. keep the bed in the low position.
- B. use a bath blanket or top sheet for warmth and privacy.
- C. constantly keep side rails raised on both sides.
- D. move back and forth from one side to the other when adjusting the linens.
Correct Answer: B
Rationale: Using a bath blanket or top sheet keeps the client warm and provides privacy. Keeping the bed in the low position and working above raised side rails might strain the nurse's back. Continually moving back and forth to tuck and arrange linen is time-consuming and disorganized.