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A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, 'I want to go outside now and smoke. It takes forever to get anything done here!' Which intervention is best for the nurse to implement?
- A. Encourage the client to use a nicotine patch.
- B. Reassure the client that it is almost time for another break.
- C. Have the client leave the unit with another staff member.
- D. Review the schedule of outdoor breaks with the client.
Correct Answer: D
Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Suggesting a nicotine patch (Option A) is not suitable as the client wants to smoke. Reassuring the client about another break (Option B) does not address the client's frustration and does not promote effective communication. Having the client leave the unit with another staff member (Option C) is not appropriate as it goes against unit rules and does not address the client's concerns. Therefore, the most appropriate intervention is to review the schedule of outdoor breaks with the client to provide clarity and address the client's frustration effectively.
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The client with cholecystitis is being instructed about dietary choices. Which meal best meets the dietary needs of this client?
- A. Steak, baked beans, and a salad
- B. Broiled fish, green beans, and an apple
- C. Pork chops, macaroni and cheese, and grapes
- D. Avocado salad, milk, and angel food cake
Correct Answer: B
Rationale: Clients with cholecystitis, which is inflammation of the gallbladder, should follow a low-fat diet to reduce symptoms. Broiled fish, green beans, and an apple (Option B) is the most suitable choice as it is low in fat. Steak, baked beans, and a salad (Option A) provide a high amount of fat and protein, which may exacerbate symptoms of cholecystitis. Pork chops, macaroni and cheese, and grapes (Option C) and avocado salad, milk, and angel food cake (Option D) contain high-fat foods that are not recommended for individuals with cholecystitis. Therefore, Option B is the most appropriate choice for a client with cholecystitis.
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.
The home care nurse is caring for a client with lung cancer with acute cancer pain. Which is the most appropriate way to assess the client's pain?
- A. The client's pain rating
- B. The nurse's impression of the client's pain
- C. Verbal and nonverbal clues from the client
- D. Pain relief after appropriate nursing intervention
Correct Answer: A
Rationale: The client's perception of pain is the hallmark of pain assessment. Usually noted by the client's rating on a scale of 1 to 10, the assessment is documented and followed with appropriate medical and nursing interventions. The nurse's impression and the verbal and nonverbal clues are subjective data. Pain relief after intervention is appropriate but relates to evaluation.
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 client finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?
- A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
- B. Sit quietly in the client's room until the client leaves the bathroom.
- C. Allow the client to cry alone and leave the client in the bathroom.
- D. Talk to the client and attempt to find out why the client is crying.
Correct Answer: D
Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option D is the correct choice as it involves directly addressing the client's emotional state and attempting to understand the reason for the distress. In a vulnerable situation like this, the nurse should take the lead in assessing and communicating with the client. Option A is incorrect as it would delegate the responsibility to someone else when the nurse should be the one to initiate the assessment. Option B is inappropriate as it does not actively address the client's emotional needs or safety. Option C is also incorrect because leaving the client alone without further assessment could potentially endanger the client's well-being.