Nokea
A client develops an irregular heart rate. Which statement made by the client who has developed an irregular heart rate indicates to the nurse that the client is ready for learning?
- A. I feel weak with an irregular pulse.
- B. What is it like to have a pacemaker?
- C. All my medications will be changed now.
- D. How can this heart rate problem affect me?
Correct Answer: D
Rationale: Learning depends on two things: physical and emotional readiness to learn. A good time to teach is when the client indicates an interest in learning, is motivated, and is physically capable of concentrating on learning. Option 4 addresses the client's readiness because the client is directly asking about the disorder. Option 1 indicates that the client is potentially physically incapable of learning at this time. The client indicates wanting to learn about pacemakers in option 2; however, the client has formed a hasty conclusion because the need for a pacemaker has not been determined. In option 3, by assuming that the medications will change, the client is emotionally unprepared for learning because the statement is based on incomplete data.
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A registered nurse (RN) is supervising a licensed practical nurse (LPN) providing care to a client with end-stage heart failure. The client is withdrawn, is reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement by the LPN to the client indicates that the LPN needs further teaching in the use of therapeutic communication skills?
- A. You are very quiet today.
- B. What are your feelings right now?
- C. Why don't you feel like getting up?
- D. Tell me more about your difficulty with sleeping at night.
Correct Answer: C
Rationale: When a 'why' question is made to the client, an explanation for feelings and behaviors is requested, and the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. In option 1, the LPN is using the therapeutic communication technique of acknowledging the client's behavior. In option 2, the LPN is encouraging identification of emotions or feelings. In option 4, the LPN is using the therapeutic communication technique of exploring, which is asking the client to describe something in more detail or to discuss it more fully.
A client with a history of seizures is prescribed phenytoin (Dilantin). Which laboratory value should the nurse monitor?
- A. Liver function tests
- B. Renal function tests
- C. Complete blood count
- D. Electrolytes
Correct Answer: A
Rationale: Phenytoin can cause hepatotoxicity, so liver function tests should be monitored regularly to detect potential liver damage early.
A mother reports to the nurse that she cannot afford the antibiotic azithromycin (Zithromax), which was ordered by the physician for her toddler's ear infection. Which of the following is the most appropriate action by the nurse?
- A. Instruct the mother on the importance of the medication
- B. Ask the mother if she knows anyone who could loan her the money
- C. Confer with the physician about whether a less expensive drug could be ordered
- D. Consult with the social worker
Correct Answer: C
Rationale: Conferring with the physician to explore a less expensive alternative medication addresses the mother's financial concern while ensuring treatment. Instructing on importance doesn't solve affordability, asking about loans is inappropriate, and a social worker may help later but isn't the first step.
The physician is calling in an order for ampicillin for a neonate. The nurse should do which of the following? Select all that apply.
- A. Write down the order.
- B. Ask the physician to come to the hospital and write the order on the chart.
- C. Repeat the order to the physician over the telephone.
- D. Ask the physician to confirm that the order is correct.
- E. Ask the nursing supervisor to cosign the telephone order as transcribed by the nurse.
Correct Answer: A,C,D
Rationale: Writing the order, repeating it back, and confirming with the physician ensure accuracy and safety for a telephone order.
A client with pneumonia is receiving oxygen at 2 L/min via nasal cannula. The nurse notes a respiratory rate of 30 breaths/min and oxygen saturation of 88%. What should the nurse do first?
- A. Increase the oxygen to 4 L/min
- B. Notify the physician
- C. Encourage deep breathing exercises
- D. Reposition the client to semi-Fowler's
Correct Answer: B
Rationale: An oxygen saturation of 88% and tachypnea indicate worsening hypoxia, requiring immediate physician notification for further orders. Increasing oxygen or repositioning may help but requires a prescription.