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A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, 'I have been told that it is harmful to bathe during my period.' Which action should the nurse take first?
- A. Accept and document the client's wish to refrain from bathing.
- B. Offer to give the client a bed bath, avoiding the perineal area.
- C. Obtain written brochures about menstruation to give to the client.
- D. Teach the importance of personal hygiene during menstruation to the client.
Correct Answer: D
Rationale: The priority for the nurse is to educate the client on the importance of personal hygiene during menstruation. Although it's crucial to respect the client's beliefs, providing education ensures the client receives accurate information to make informed decisions about her hygiene practices. By offering teaching first, the nurse can address any misconceptions or concerns the client may have while promoting optimal hygiene practices for overall well-being. Choice A should not be the first action as it does not address the client's potential misinformation about hygiene. Choice B is not ideal as it only offers a temporary solution without addressing the underlying issue. Choice C is not the priority as the immediate concern is the client's personal hygiene practices.
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In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?
- A. Witness the client's signature on the permit.
- B. Answer the client's questions about the surgery.
- C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery.
- D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.
Correct Answer: C
Rationale: The nurse should inform the surgeon promptly that the operative permit is not signed and the client has questions about the surgery. It is crucial for the surgeon to be aware of these issues as it is their responsibility to explain the procedure to the client and ensure that the necessary consent is obtained before proceeding with the surgery. Answering the client's questions directly (choice B) may not be appropriate as the surgeon is the one responsible for providing detailed information about the procedure. Witnessing the client's signature (choice A) is premature since the permit is not signed. Reassuring the client (choice D) is not the most appropriate action at this point; the priority is to involve the surgeon in addressing the unsigned permit and the client's questions.
A client with cirrhosis and ascites is receiving furosemide 40 mg BID. The pharmacy provides 20 mg tablets. How many tablets should the client receive each day? [Enter numeric value only]
- A. 4 tablets
- B. 3 tablets
- C. 2 tablets
- D. 1 tablet
Correct Answer: A
Rationale: To calculate the total daily dose of furosemide needed, 40 mg BID (twice a day) is 80 mg/day. Since each tablet is 20 mg, the client should receive a total of 4 tablets per day (80 mg · 20 mg per tablet = 4 tablets). Therefore, the correct answer is 4 tablets. Choice B (3 tablets) is incorrect because it does not provide the correct total daily dose. Choice C (2 tablets) is incorrect as it would not meet the required dose of 80 mg/day. Choice D (1 tablet) is incorrect as it would be insufficient to achieve the prescribed daily dose.
A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?
- A. Document the client's temperature fluctuations
- B. Assess for flushed, warm skin consistently
- C. Measure temperature at regular intervals
- D. Use different sites for temperature measurement
Correct Answer: C
Rationale: To assess fever patterns accurately, the nurse should measure the client's temperature at regular intervals. This approach helps in identifying the pattern of fever spikes and fluctuations, which can provide valuable information for diagnostic and treatment purposes. Assessing for flushed, warm skin or documenting circadian rhythms may not directly reveal the fever pattern, while varying temperature measurement sites could lead to inconsistent readings. Therefore, measuring temperature at regular intervals is the most appropriate intervention to identify fever patterns in this scenario.
A client with a history of coronary artery disease (CAD) is admitted with chest pain. Which intervention should the nurse implement first?
- A. Administer sublingual nitroglycerin
- B. Obtain a 12-lead electrocardiogram (ECG)
- C. Apply oxygen via nasal cannula
- D. Initiate continuous cardiac monitoring
Correct Answer: C
Rationale: In a client with a history of coronary artery disease (CAD) experiencing chest pain, the priority intervention for the nurse to implement first is to apply oxygen via nasal cannula. Oxygenation is crucial to ensure adequate oxygen supply to the tissues and the heart. This intervention takes precedence over administering sublingual nitroglycerin, obtaining an ECG, or initiating continuous cardiac monitoring. While these interventions are important, ensuring adequate oxygenation is the initial priority in the management of a client with chest pain.
A client is admitted with a diagnosis of fluid volume excess. Which intervention should the nurse include in the client's plan of care?
- A. Encourage increased fluid intake.
- B. Place the client in a high Fowler's position.
- C. Measure the client's intake and output.
- D. Restrict dietary sodium intake.
Correct Answer: D
Rationale: Restricting dietary sodium intake (D) is the most critical intervention for a client with fluid volume excess to prevent further fluid retention. Encouraging increased fluid intake (A) would exacerbate the issue by adding more fluid to the body. Placing the client in a high Fowler's position (B) is more relevant for respiratory issues than fluid volume excess. While measuring intake and output (C) is important for assessing fluid balance, restricting sodium intake is the priority as it helps manage fluid levels more effectively by reducing fluid retention.