Nokea
Which of the following statements should the nurse make?
- A. Do you need a prescription for an antianxiety medication?
- B. Do you need information on hospice care?
- C. Would you like to talk to a counselor about advance directives?
- D. Would you like to speak to a spiritual advisor?
Correct Answer: D
Rationale: Spiritual support can help address emotional and existential concerns in terminally ill clients.
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Which of the following food choices should the nurse include on the client's food tray?
- A. Bacon and cheese quiche with milk
- B. Scrambled eggs and toast with milk
- C. Shrimp salad and tomato soup with milk
- D. Ham sandwich with milk
Correct Answer: B
Rationale: Kosher diets exclude pork and shellfish.
A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning.(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Apply suction while rotating the catheter.
- B. Rinse the catheter to remove secretions:
- C. Dan sterile gloves.
- D. Insert the catheter during the client's inspiration.
- E. Turn on the suction and set the pressure
Correct Answer: C,D,E,A,B
Rationale: To perform nasotracheal suctioning correctly, the nurse should follow these steps:
1. Dan sterile gloves (C): Ensures aseptic technique to prevent infection.
2. Insert the catheter during the client's inspiration (D): Reduces the risk of hypoxia and trauma.
3. Turn on the suction and set the pressure (E): Prepares the equipment for suctioning.
4. Apply suction while rotating the catheter (A): Maximizes removal of secretions.
5. Rinse the catheter to remove secretions (B): Ensures cleanliness of the catheter for next use.
Other choices are incorrect:
- F and G are not applicable in this sequence as they do not contribute to the safe and effective performance of nasotracheal suctioning.
A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?
- A. Using an electronic messaging system to remind clients when to take medications
- B. Educating clients about contraindications to specific immunizations
- C. Helping clients understand health screenings covered by their insurance plans
- D. Providing clients with information about the benefits of exercise
Correct Answer: A
Rationale: The correct answer is A because using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention. Tertiary prevention focuses on managing and improving the quality of life for individuals already diagnosed with a disease. In this case, reminding clients to take medications helps prevent complications and progression of HIV. The other choices are incorrect because: B is an example of primary prevention as it aims to prevent the occurrence of a disease; C is related to secondary prevention as it involves early detection and prevention of complications; D is a form of health promotion rather than prevention.
Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?
- A. Implement firm but flexible boundaries in their relationship
- B. Encourage authoritative communication from the adult child
- C. Decrease socialization with extended relatives until roles are identified,
- D. Minimize open discussion regarding the changes to avoid embarrassment.
Correct Answer: A
Rationale: Boundaries foster healthy family dynamics during role adjustments.
Which of the following actions should the nurse take first?
- A. Teach the client how to insert the diaphragm
- B. Document the client's level of understanding about potential adverse effects.
- C. Supervise return demonstration of diaphragm use
- D. Determine the client's knowledge about diaphragm use
Correct Answer: D
Rationale: Assessing the client’s current knowledge is the first step in patient education.