Nokea
A client admitted with sudden onset of severe back pain of unknown origin. Which statement would be most effective for the nurse to use to elicit further information from this client about his pain?
- A. Tell me how you are feeling right now.
- B. Describe the pain you are experiencing.
- C. Can you tell me more about your back pain?
- D. When did the pain start and how severe is it?
Correct Answer: B
Rationale: The correct answer is B: 'Describe the pain you are experiencing.' This question is the most effective as it prompts the client to provide detailed information about the nature of the pain, including its characteristics, intensity, and location. This detailed description can help the nurse in assessing the possible cause and severity of the pain. Choices A, C, and D are not as effective as they are either too general ('Tell me how you are feeling right now'), redundant ('Can you tell me more about your back pain?'), or focused only on timing and severity ('When did the pain start and how severe is it?').
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A client with a tracheostomy collar has a decrease in heart rate and oxygen saturation during tracheal suctioning. Which of the following actions should the nurse take?
- A. Elevate the head of the bed.
- B. Remove the inner cannula.
- C. Irrigate the stoma.
- D. Discontinue suctioning.
Correct Answer: D
Rationale: The correct action for the nurse to take in this situation is to discontinue suctioning. Suctioning should be stopped immediately to prevent further decrease in heart rate and oxygen saturation. Elevating the head of the bed may help with oxygenation, but the priority is to stop the suctioning procedure. Removing the inner cannula or irrigating the stoma are not appropriate actions and could worsen the client's condition.
At the time of the first dressing change, the client refuses to look at her mastectomy incision. The LPN tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence?
- A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel.
- B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery.
- C. It is OK if you don't want to talk about your surgery. I will be available when you are ready.
- D. I will ask a woman who has had a mastectomy to come by and share her experiences with you.
Correct Answer: C
Rationale: In this situation, it's essential to acknowledge and respect the client's feelings and choices. Choice C is the most appropriate response as it validates the client's decision not to discuss the surgery while offering support and understanding. Giving the client space and letting them know you will be available when they are ready shows empathy and fosters trust. Choices A and B do not respect the client's autonomy and may come across as dismissive or pressuring. Choice D assumes the client needs advice from someone who has had a similar experience without considering the client's current emotional state and preferences.
A healthcare professional is assessing a client's oculomotor nerve functions. Which of the following actions should the healthcare professional take?
- A. Check the client's pupillary reaction to light
- B. Ask the client to read print from the Snellen chart
- C. Ask the client to identify different scents
- D. Use cotton to lightly touch the client's cornea
Correct Answer: A
Rationale: Checking the client's pupillary reaction to light is a key assessment to evaluate the oculomotor nerve function. The oculomotor nerve controls the pupil's constriction response to light. Choices B, C, and D are incorrect because testing vision with a Snellen chart, identifying scents, or touching the cornea are not specific assessments for oculomotor nerve function.
A client is being treated for diabetic ketoacidosis (DKA). Which laboratory value would be most concerning?
- A. Blood glucose of 350 mg/dL
- B. Serum bicarbonate of 18 mEq/L
- C. Arterial pH of 7.20
- D. Serum potassium of 5.5 mEq/L
Correct Answer: C
Rationale: In a client with diabetic ketoacidosis (DKA), the most concerning laboratory value is an arterial pH of 7.20. An arterial pH of 7.20 indicates severe acidosis, which is a critical condition requiring immediate intervention. This pH level reflects a significant imbalance in the body's acid-base status, potentially leading to serious complications. High blood glucose levels (choice A) are expected in DKA but do not directly indicate the severity of acidosis. A serum bicarbonate level of 18 mEq/L (choice B) is low but not as immediately critical as a pH of 7.20. Serum potassium of 5.5 mEq/L (choice D) is elevated, which can occur in DKA due to insulin deficiency, but it is not the most concerning value in this scenario.
A healthcare professional is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the healthcare professional include in the plan?
- A. Empty the drainage bag at least every 8 hours
- B. Keep the drainage bag below the level of the bladder
- C. Use sterile technique to collect a specimen from the drainage system
- D. Secure the catheter to the lower abdomen with a securement device
Correct Answer: B
Rationale: The correct action to include in the plan is to keep the drainage bag below the level of the bladder. This positioning helps ensure proper drainage and prevents backflow of urine into the bladder, reducing the risk of urinary tract infections. Emptying the drainage bag regularly is important, typically every 4-8 hours or when it is half-full, to maintain adequate flow and prevent infection (Choice A is incorrect). Using a sterile technique to collect specimens from the drainage system is crucial to prevent introducing pathogens into the urinary tract, so clean technique should not be used (Choice C is incorrect). Taping the catheter to the lower abdomen is not recommended as it can cause tension on the catheter, leading to discomfort and potential trauma to the urethra (Choice D is incorrect).