Nokea
A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?
- A. To observe the type and amount of nasogastric tube drainage
- B. Monitor the client for nausea or other complications
- C. Irrigate the nasogastric tube with the ordered irrigation solution
- D. Perform nostril and mouth care
Correct Answer: D
Rationale: Performing nostril and mouth care is a non-invasive task that can be safely delegated to an unlicensed assistive personnel (UAP). Observing the type and amount of nasogastric tube drainage requires assessment skills and understanding of potential complications, making it more appropriate for a licensed healthcare professional. Monitoring the client for nausea or other complications involves interpreting client responses and identifying adverse reactions, which also requires a licensed healthcare professional. Irrigating the nasogastric tube with the ordered solution involves a procedure that can impact the client's condition and should be performed by a licensed healthcare professional to prevent complications.
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The nurse is caring for a client who had a myocardial infarction 6 hours ago. The primary goal of care at this time is to
- A. Limit the effects of tissue damage
- B. Relieve pain and anxiety
- C. Prevent arrhythmias
- D. Reduce anxiety
Correct Answer: A
Rationale: The correct answer is A: 'Limit the effects of tissue damage.' After a myocardial infarction, the primary goal of care is to limit the damage to the heart muscle. This includes interventions to improve blood flow, oxygenation, and prevent further complications. Choice B ('Relieve pain and anxiety') is important but secondary to addressing tissue damage. Choice C ('Prevent arrhythmias') is also crucial but falls under the broader goal of limiting tissue damage. Choice D ('Reduce anxiety') is essential for holistic care but is not the primary goal immediately after a myocardial infarction.
A client is prescribed metformin for type 2 diabetes. What should the nurse emphasize in the client's teaching?
- A. Take the medication with meals to reduce the risk of GI upset.
- B. Report any muscle pain to the healthcare provider promptly.
- C. Avoid alcohol consumption while taking this medication.
- D. Monitor blood sugar levels regularly to prevent hypoglycemia.
Correct Answer: C
Rationale: The correct answer is to avoid alcohol consumption while taking metformin. Alcohol can increase the risk of lactic acidosis when combined with metformin. Choice A is incorrect because metformin is usually recommended to be taken with meals to reduce GI upset. Choice B is important but not the priority; muscle pain is more commonly associated with other diabetes medications. Choice D is incorrect because metformin typically does not cause hypoglycemia but rather helps control blood sugar levels in type 2 diabetes.
A client who has been prescribed multiple antihypertensive medications experiences syncope and has a blood pressure of 70/40. What is the rationale for the nurse to hold the next scheduled antihypertensive dose?
- A. Increased urinary clearance of the medications has produced diuresis, lowering the blood pressure.
- B. The antagonistic interaction of the medications has reduced their effectiveness.
- C. The synergistic effect of the medications has resulted in drug toxicity, causing hypotension.
- D. The additive effect of the medications has lowered the blood pressure too much.
Correct Answer: D
Rationale: The additive effect of multiple antihypertensive medications can cause hypotension, leading to dangerously low blood pressure. In this scenario, the client experiencing syncope with a blood pressure of 70/40 indicates severe hypotension, likely due to the combined action of the antihypertensive medications. Holding the next scheduled dose is essential to prevent further lowering of blood pressure and potential complications. Choices A, B, and C provide inaccurate explanations and do not align with the client's presentation and the need to manage hypotension caused by the additive effect of the medications.
When assessing a client, why is it important for the nurse to be informed about cultural issues related to the client's background?
- A. Normal patterns of behavior may be labeled as deviant, immoral, or insane
- B. The meaning of the client's behavior can be derived from conventional wisdom
- C. Personal values will guide the interaction between individuals from different cultures
- D. The nurse should rely on her knowledge of different developmental mental stages
Correct Answer: A
Rationale: Being aware of cultural differences is crucial because normal behaviors in one culture may be perceived as deviant, immoral, or insane in another. This awareness helps the nurse avoid misunderstandings or misinterpretations of behaviors that are considered acceptable in the client's cultural context but may be viewed differently in another. Choices B, C, and D are incorrect because understanding cultural issues goes beyond deriving meanings from conventional wisdom, personal values guiding interactions, or relying solely on knowledge of developmental mental stages.
The nurse is providing discharge teaching to a client with asthma. Which statement indicates the client understands how to use a rescue inhaler?
- A. I will use my rescue inhaler every morning to prevent asthma attacks.
- B. I should use my rescue inhaler when I start to experience wheezing.
- C. I will use my rescue inhaler when my peak flow meter reading is in the green zone.
- D. I will only use my rescue inhaler before going to bed.
Correct Answer: B
Rationale: The correct answer is B: 'I should use my rescue inhaler when I start to experience wheezing.' A rescue inhaler is used during the onset of asthma symptoms, such as wheezing, to quickly open the airways. It is not intended for routine daily use or prevention, which is the role of a maintenance inhaler. Option A is incorrect because a rescue inhaler is not used for prevention but for immediate relief during an asthma attack. Option C is incorrect because the peak flow meter reading is used to monitor asthma control, not to determine when to use a rescue inhaler. Option D is incorrect because using a rescue inhaler only before going to bed does not address the need for immediate relief when wheezing or experiencing asthma symptoms.