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A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include?
- A. Writing a prescription for morphine sulfate as needed for pain
- B. Inserting a nasogastric (NG) tube to relieve gastric distention
- C. Showing a client how to use progressive muscle relaxation
- D. Performing a daily bath after the evening meal
Correct Answer: C
Rationale: The correct answer is C. Showing a client how to use progressive muscle relaxation is an intervention that does not require a provider's prescription. This falls within the nurse's scope of practice and can be implemented to promote relaxation and reduce stress for the client. Choices A and B involve tasks that require a provider's prescription and specialized training. Writing a prescription for morphine sulfate and inserting an NG tube should only be done by authorized healthcare providers. Choice D, performing a daily bath, while within the nurse's scope, does not specifically address interventions that do not require a provider's prescription.
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A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients?
- A. Members of the same religion may have varying feelings about their religion.
- B. A shared religion background does not guarantee identical beliefs.
- C. The same religious beliefs can influence individuals differently.
- D. Discussing differences and commonalities in beliefs may not always be relevant.
Correct Answer: C
Rationale: The correct answer is C. Religious beliefs can vary widely even among individuals of the same faith. It is essential for the nurse to recognize that the impact and interpretation of religious beliefs can differ from person to person. Choice A is incorrect as individuals within the same religion can have diverse feelings and interpretations. Choice B is incorrect because a shared religious background does not necessarily mean that individuals hold the same beliefs. Choice D is not the best course of action as discussing differences and commonalities in beliefs may not always be necessary or appropriate for providing care.
The nurse is providing discharge teaching to a client who has been prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?
- A. I will avoid eating foods high in vitamin K.
- B. I will take my medication at the same time every day.
- C. I will use a soft toothbrush to prevent gum bleeding.
- D. I can take aspirin if I have a headache.
Correct Answer: D
Rationale: The correct answer is D: 'I can take aspirin if I have a headache.' This statement indicates a need for further teaching because aspirin can increase the risk of bleeding in clients taking warfarin. Clients on warfarin therapy should avoid taking aspirin or other medications that increase the risk of bleeding. Choices A, B, and C are correct statements that show understanding of warfarin therapy, such as the importance of avoiding foods high in vitamin K, taking medication consistently, and using a soft toothbrush to prevent gum bleeding.
During a skin assessment, a client expresses concern about skin cancer due to a lesion on the anterior thigh. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?
- A. An uneven shape
- B. A uniformly colored lesion
- C. A lesion that is small and flat
- D. A lesion that is less than 1 cm in diameter
Correct Answer: A
Rationale: An uneven shape of a lesion is a common characteristic of malignant skin lesions. Asymmetric or irregularly shaped lesions are concerning for skin cancer and should be reported promptly for further evaluation and management. Choice B, a uniformly colored lesion, is more indicative of a benign lesion as malignant lesions often exhibit variations in color. Choice C, a lesion that is small and flat, does not necessarily indicate malignancy by itself. Choice D, a lesion that is less than 1 cm in diameter, is more suggestive of a benign lesion, as malignant lesions are typically larger in size.
A healthcare provider is providing teaching to a client who has a new medication prescription. Which of the following manifestations of a mild allergic reaction should the healthcare provider include?
- A. Ptosis
- B. Hematuria
- C. Urticaria
- D. Nausea
Correct Answer: C
Rationale: Urticaria, also known as hives, is a common manifestation of a mild allergic reaction. Ptosis refers to drooping of the eyelid and is not typically associated with allergic reactions. Hematuria indicates blood in the urine and is not a typical allergic reaction symptom. Nausea can occur with various conditions, but it is not a specific manifestation of a mild allergic reaction.
When planning to perform passive range-of-motion exercises for a client, what action should a healthcare professional take?
- A. Repeat each joint motion five times during each session.
- B. Perform the exercises quickly to save time.
- C. Focus only on the most affected joints.
- D. Assess the client's range of motion before starting.
Correct Answer: A
Rationale: The correct answer is to repeat each joint motion five times during each session. Repetition is crucial to maintaining joint flexibility and muscle function. By ensuring each joint motion is repeated, the client can benefit fully from the passive range-of-motion exercises. Choice B is incorrect because quick performance may compromise technique and risk injury. Choice C is incorrect as neglecting less affected joints can lead to imbalances and hinder overall progress. Choice D is incorrect as assessing the client's range of motion beforehand is vital, but it is not the immediate action to take during the exercise session.