Nokea
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?
- A. Decrease intake of fluids after the evening meal.
- B. Drink a glass of cranberry juice every day.
- C. Drink a glass of warm decaffeinated beverage at bedtime.
- D. Consult the healthcare provider about a sleeping pill.
Correct Answer: A
Rationale: The correct instruction for the nurse to provide is to advise the client to decrease intake of fluids after the evening meal. By reducing fluid intake before bedtime, the client can minimize the need to void during the night, which can help improve sleep patterns affected by nocturia. Choices B, C, and D are incorrect. Drinking cranberry juice or warm decaffeinated beverage at bedtime may increase fluid intake, exacerbating the nocturia issue. Consulting the healthcare provider about a sleeping pill should not be the first intervention, as it is important to try non-pharmacological approaches first.
You may also like to solve these questions
Why is it most important to start intravenous infusions in the upper extremities rather than the lower extremities of adults?
- A. Superficial veins are more easily found in the feet and ankles.
- B. A decreased flow rate could lead to thrombosis formation.
- C. It is more challenging to move a cannulated extremity when using the leg or foot.
- D. Veins in the feet and ankles are located deep, making the procedure more painful.
Correct Answer: B
Rationale: The most critical reason for initiating intravenous infusions in the upper extremities of adults is to reduce the risk of thrombosis (B). Venous return is typically better in the upper extremities, decreasing the likelihood of thrombus formation, which could be life-threatening if dislodged. Although superficial veins are easily found in the feet and ankles (A), this is not the primary reason for choosing the upper extremities. Handling a leg or foot with an IV (C) is not significantly more challenging than handling an arm or hand. The depth of veins in the feet and ankles (D) does not primarily determine the site for IV placement.
What is the most important action for the nurse to take when caring for a client with a spinal cord injury experiencing autonomic dysreflexia?
- A. Elevate the head of the bed to 45 degrees.
- B. Monitor the client's respiratory rate.
- C. Administer an antihypertensive medication.
- D. Assess the client's blood glucose level.
Correct Answer: A
Rationale: In a client with autonomic dysreflexia, the most critical action is to elevate the head of the bed to 45 degrees (A). This positioning helps reduce blood pressure, which is essential in managing autonomic dysreflexia. Monitoring the client's respiratory rate (B) is important for overall assessment but not the priority in this situation. Administering an antihypertensive medication (C) without addressing the positioning issue first can lead to further complications. Assessing the client's blood glucose level (D) is not directly related to autonomic dysreflexia and is not the initial priority in this scenario.
The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?
- A. Perform range-of-motion exercises to prevent contractures.
- B. Decrease the client's fluid intake to prevent diarrhea.
- C. Massage the client's legs to reduce the occurrence of embolisms.
- D. Turn the client from side to back every shift.
Correct Answer: A
Rationale: Performing range-of-motion exercises is essential in preventing contractures, which are common complications of immobility. These exercises help maintain joint flexibility and muscle strength, reducing the risk of contractures that can lead to functional limitations or pain for the client. Choices B, C, and D are incorrect. Decreasing fluid intake does not prevent immobility complications, but it can lead to dehydration. Massaging the client's legs does not directly address the prevention of immobility complications like contractures. Turning the client from side to back every shift is important for preventing pressure ulcers but does not directly address complications of immobility like contractures.
A client with a diagnosis of asthma is receiving albuterol (Proventil) via a metered-dose inhaler (MDI). Which assessment finding indicates that the medication is effective?
- A. Increased oxygen saturation.
- B. Decreased respiratory rate.
- C. Absence of audible wheezing.
- D. Improved exercise tolerance.
Correct Answer: A
Rationale: Increased oxygen saturation (A) is the most direct indicator of the effectiveness of albuterol (Proventil) in improving breathing. Oxygen saturation reflects the amount of oxygen in the blood, showing that the albuterol is helping with air exchange in the lungs. While decreased respiratory rate (B), absence of audible wheezing (C), and improved exercise tolerance (D) are positive outcomes, they are secondary to oxygen saturation. Oxygen saturation directly reflects the improvement in the client's respiratory status and the effectiveness of the medication.
The healthcare provider is preparing an older client for discharge. Which method is best for the provider to use when evaluating the client's ability to perform a dressing change at home?
- A. Determine the client's feelings about changing the dressing.
- B. Ask the client to write a description of the procedure.
- C. Have a family member evaluate the client's ability to change the dressing.
- D. Observe the client performing an unassisted dressing change.
Correct Answer: D
Rationale: Direct observation of the client performing the skill is the most effective method to assess the client's ability to independently change the dressing. This allows the healthcare provider to evaluate the client's technique, understanding, and readiness to perform the task at home. Choices A, B, and C are not as reliable as directly observing the client performing the dressing change. Determining the client's feelings may not accurately reflect their ability, asking the client to write about the procedure may not demonstrate their practical skills, and having a family member evaluate might not provide an accurate assessment of the client's ability.