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A charge nurse on a long-term care unit is working with an assistive personnel who states, 'I am tired of all the changes on this unit. If things don't improve soon, I'm requesting a transfer.' Which of the following responses should the charge nurse make?
- A. Why don't you just file a formal complaint with Human Resources?
- B. Please, try to wait a little longer. Things will get better soon.
- C. There has been too much complaining about these changes.
- D. So, you are upset about all of the recent changes on the unit?
Correct Answer: D
Rationale: Reflecting the AP's feelings fosters communication and addresses concerns constructively.
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A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Stand with the crutch tips against the feet.
- B. Hold the arms straight when walking.
- C. Keep the crutches at the level of the axillae.
- D. Bear weight on the unaffected leg.
Correct Answer: D
Rationale: The three-point gait involves bearing weight on the unaffected leg while advancing crutches and the affected leg.
A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. Family history of osteoporosis
- B. Type 1 diabetes mellitus
- C. Orthostatic hypotension
- D. BMI of 24
Correct Answer: B
Rationale: Type 1 diabetes increases cardiovascular risk due to chronic hyperglycemia affecting blood vessels.
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps placing them in the order of performance. Use all the steps.)
- A. Wipe the inside of the inner cannula with a folded pipe cleaner.
- B. Unlock and remove the inner cannula.
- C. Scrub the inside and outside of the inner cannula with a small brush
- D. Cleanse the stoma site with 0.9% sodium chloride solution.
- E. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
Correct Answer: E,B,C,A,D
Rationale: E: Prepare solution. B: Remove cannula. C: Scrub cannula. A: Wipe cannula. D: Cleanse stoma ensures sterile technique.
A home health nurse is reinforcing teaching about dietary needs with the child of a client. They state, 'I don't know what to do because they're not eating.' Which of the following responses should the nurse make?
- A. Why do you think they're not eating?
- B. Tell me more about what happens at mealtime.
- C. They may need a feeding tube.
- D. I'm sure it's nothing serious and their appetite will return soon.
Correct Answer: B
Rationale: Exploring mealtime details gathers specific data to address the eating issue effectively.
A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?
- A. Dangle your legs over the side of the bed.
- B. Use your incentive spirometer.
- C. Increase your intake of protein.
- D. Perform regular isometric exercises.
Correct Answer: A
Rationale: Dangling legs before standing allows gradual adjustment to upright posture, reducing orthostatic hypotension risk.