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A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action?
- A. Discharge the client from home health care because of noncompliance
- B. Notify the provider of the client's failure to follow prescribed diet
- C. Discuss diet with the client to learn the reasons for not following the diet
- D. Make a referral to Meals-on-Wheels
Correct Answer: C
Rationale: Discuss diet with the client to learn the reasons for not following the diet. When new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting findings to the provider, it is best to have a complete understanding of the client's behavior and feelings as a basis for future teaching and intervention.
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After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond by saying
- A. He has a lot of problems. You need to have patience with him.
- B. I will talk with him and try to figure out what to do.
- C. He may be scared and taking it out on you. Let's talk to figure out what to do.
- D. Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day.
Correct Answer: C
Rationale: This response explains the client's behavior without belittling the UAP's feelings. The UAP is encouraged to contribute to the plan of care to help solve the problem.
The client that the nurse is ambulating becomes dizzy and feels faint. Place the nurse's actions in the correct order to prevent the client from falling.
- A. Support and ease the client to the floor by sliding the client down the forward leg
- B. Call for help
- C. Bend at the knees and pull the client toward the forward leg
- D. Assess the client for injuries
- E. Protect the client's head from hitting objects on the floor
- F. Assume a broad stance with the stronger leg somewhat behind the other leg
Correct Answer: B,F,C,A,E,D
Rationale: The sequence ensures safety: call for help (B), establish a stable stance (F), lower the client safely (C, A), protect the head (E), and assess injuries (D).
A 6-year-old is admitted to the ED after ingesting oxycodone tablets that had been prescribed for the parent. The parent provides the prescription bottle that originally contained 15 tablets of oxycodone 5 mg. The parent stated taking 3 tablets. There are 9 tablets remaining in the bottle. If the child ingested the missing tablets, how many mg of oxycodone did the child ingest?
Correct Answer: 15
Rationale: 15 - 3 = 12; 12 - 9 = 3; 3 tablets x 5 mg = 15 mg. The child ingested 15 mg of oxycodone.
A client continuously calls out to the nursing staff when anyone passes the client’s door and asks them to do something in the room. The best response by the charge nurse would be to
- A. keep the client’s room door cracked to minimize the distractions
- B. assign 1 of the nursing staff to visit the client regularly
- C. reassure the client that 1 staff person will check frequently if the client needs anything
- D. arrange for each staff member to go into the client’s room to check on needs every hour on the hour
Correct Answer: B
Rationale: Assign 1 of the nursing staff to visit the client regularly. Regular, frequent, planned contact by 1 staff member provides continuity of care and communicates to the client that care will be available when needed.
The nurse is caring for a client who has just returned from the operating room after a cholecystectomy. Which of these findings requires immediate follow-up by the nurse?
- A. A temperature of 100.4°F (38°C)
- B. Pulse rate of 110 beats per minute
- C. Respiratory rate of 24 breaths per minute
- D. Oxygen saturation of 88%
Correct Answer: D
Rationale: An oxygen saturation of 88% indicates hypoxia, requiring immediate intervention to prevent respiratory compromise.