Nokea
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide?
- A. Take a vitamin supplement tablet once a day.
- B. Change positions in the chair at least every hour.
- C. Increase daily intake of water or other oral fluids.
- D. Purchase a newer model wheelchair.
Correct Answer: B
Rationale: The most important instruction for the nurse to provide to the client is to change positions in the chair at least every hour. This is crucial to prevent pressure ulcers, as prolonged pressure on the skin can lead to tissue damage. Repositioning helps relieve pressure on vulnerable areas like the sacrum. Increasing fluid intake can also aid in preventing skin breakdown by maintaining skin hydration. While a vitamin supplement may support overall health, it is not as critical as repositioning to prevent pressure ulcers. Purchasing a new wheelchair is an expensive intervention and should be considered a last resort after implementing less costly preventive measures.
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The nurse is caring for a client who is recovering from an episode of autonomic hyperreflexia. Which statement should the nurse make to the client to most encourage therapeutic communication?
- A. How could your home care nurse let this happen?
- B. Now that this problem is taken care of, I'm sure you'll be fine.
- C. I have some time if you would like to talk about what happened to you.
- D. I'm sure you now understand the importance of preventing this from occurring.
Correct Answer: C
Rationale: Option 3 encourages the client to discuss his or her feelings. Options 1 and 4 show disapproval, and option 2 provides false reassurance; these are nontherapeutic techniques.
The client is being instructed on the proper use of a metered-dose inhaler. Which instruction should the nurse provide to ensure the optimal benefits from the drug?
- A. Fill your lungs with air through your mouth and then compress the inhaler.
- B. Compress the inhaler while slowly breathing in through your mouth.
- C. Compress the inhaler while inhaling quickly through your nose.
- D. Exhale completely after compressing the inhaler and then inhale.
Correct Answer: B
Rationale: To ensure optimal benefits from a metered-dose inhaler, the client should be instructed to compress the inhaler while slowly breathing in through the mouth. This technique facilitates the medication to reach deep into the lungs, allowing for an optimal bronchodilation effect. Option B is correct as it promotes the proper coordination of inhaler compression and inhalation, ensuring effective drug delivery. Options A, C, and D are incorrect as they do not support deep lung penetration of the medication, which is essential for its effectiveness in treating respiratory conditions.
After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?
- A. Provide the client with a list of reliable internet sites that offer information on medications.
- B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
- C. Reassure the client that information about the medication is included in the written instructions.
- D. Encourage the client to call the clinic nurse or healthcare provider if any questions arise.
Correct Answer: D
Rationale: To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or healthcare provider if any questions arise. This direct communication allows for personalized assistance and clarification tailored to the client's specific concerns. Providing Internet sites (Choice A) may lead to unreliable information, and a drug reference book (Choice B) may not address individualized questions. While the written instructions may contain information (Choice C), they may not cover all potential queries the client might have, making direct contact with the healthcare provider the most appropriate option.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
- A. Apply a warm compress proximal to the site.
- B. Check for kinks in the tubing and raise the IV pole.
- C. Adjust the tape that stabilizes the needle.
- D. Change the IV solution bag.
Correct Answer: B
Rationale: When a nurse assesses a slowed IV rate by gravity with a healthy venous access site in a 2-year-old admitted for dehydration, the next step would be to check for kinks in the tubing and raise the IV pole. This action ensures that the IV fluid can flow freely and reach the patient at the correct rate. Applying a warm compress proximal to the site (Choice A) is not indicated in this situation as it does not address the underlying issue of a slowed IV rate due to mechanical factors. Adjusting the tape that stabilizes the needle (Choice C) or changing the IV solution bag (Choice D) are not the priority actions in this case. These choices do not address the issue of a slowed IV rate caused by kinks in the tubing or the height of the IV pole, which are more likely reasons for the problem observed.
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next?
- A. Document that the client responds to the painful stimulus.
- B. Observe the client's response to verbal stimulation.
- C. Place the client on seizure precautions for 24 hours.
- D. Report decorticate posturing to the health care provider.
Correct Answer: A
Rationale: The correct action for the nurse to take next is to document that the client responds to the painful stimulus. In this scenario, the client has shown a purposeful response to pain by wincing and pulling away, which should be accurately documented. Verbal stimulation assessment typically follows the assessment of responses to painful stimuli. Placing the client on seizure precautions is not warranted based solely on the observed response to a painful stimulus. Decorticate posturing, which involves abnormal flexion movements, is not demonstrated by the client in this case, making it unnecessary to report to the provider.