Nokea
A client is 6 hours postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?
- A. Allow the client to hear running water while attempting to void
- B. Provide the client with a bedpan while sitting upright
- C. Insert an indwelling urinary catheter and connect it to gravity drainage
- D. Encourage the client to limit fluid intake
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to allow the client to hear running water while attempting to void. This can help stimulate the urge to urinate in a non-invasive way, promoting natural voiding. Providing a bedpan while sitting upright is also a suitable approach to facilitate voiding by encouraging a more natural position. Inserting an indwelling urinary catheter should be a last resort due to infection risks and discomfort associated with catheterization. Encouraging the client to limit fluid intake is not appropriate as hydration is crucial for overall health and can aid in promoting voiding. Therefore, the best initial intervention to promote voiding in this scenario is to allow the client to hear running water.
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A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?
- A. Take the medication with food.
- B. Place the tablet under your tongue and let it dissolve completely.
- C. Swallow the tablet whole with a glass of water.
- D. Chew the tablet for faster relief.
Correct Answer: B
Rationale: The correct instruction for a client prescribed nitroglycerin sublingual tablets is to place the tablet under the tongue and let it dissolve completely. This route of administration allows for rapid absorption of the medication through the oral mucosa, providing quick relief for angina symptoms. Option A, taking the medication with food, is incorrect as nitroglycerin should be taken sublingually, not with food. Option C, swallowing the tablet whole with water, is incorrect as sublingual tablets should not be swallowed whole. Option D, chewing the tablet for faster relief, is also incorrect as chewing the tablet can lead to rapid absorption and potential adverse effects rather than a controlled release for angina relief.
The patient refuses to bathe in the morning, stating a preference for evening baths. What is the best action for the nurse?
- A. Defer the bath until evening and pass on the information to the next shift.
- B. Tell the patient that daily morning baths are part of the 'normal' routine.
- C. Explain the importance of maintaining morning hygiene practices.
- D. Cancel hygiene for the day and attempt again in the morning.
Correct Answer: A
Rationale: The best action by the nurse is to respect the patient's preference and autonomy. Defer the bath until evening to allow the patient to follow their usual hygiene routine. Passing on the information to the next shift ensures continuity of care. Choice B is incorrect because it disregards the patient's preference and autonomy. Choice C, while important, does not address the patient's immediate concern. Choice D is incorrect as it does not respect the patient's wishes and may lead to further resistance to bathing.
Which statement by the mother indicates that the mother understands safety precautions with her four-month-old infant and her 4-year-old child?
- A. I secure the infant car seat in the back seat facing backwards.
- B. I place my infant in the middle of the living room floor on a blanket to play with my 4-year-old while I make supper in the kitchen.
- C. My sleeping baby looks adorable in the crib with the little buttocks up in the air while the four-year-old naps on the sofa.
- D. I have the 4-year-old hold and help feed the four-month-old a bottle in the kitchen while I make supper.
Correct Answer: D
Rationale: Choice D is the correct answer because having the 4-year-old help feed the four-month-old a bottle in the kitchen while the mother makes supper shows supervision of the infant by the older child in a safe environment. This choice indicates that the mother understands safety precautions by involving the older child in a caregiving task under her supervision. Choices A, B, and C are incorrect because they involve unsafe practices such as placing the infant on the floor unsupervised, positioning the infant car seat in the front seat, and not providing direct supervision of the children during naptimes.
A client with an NG tube is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?
- A. Rinse the feeding bag with water between feedings
- B. Tell the client to keep the head of the bed elevated at least 30°
- C. Make sure the enteral formula is at room temperature
- D. Wipe the top of the formula can with alcohol
Correct Answer: B
Rationale: The correct answer is to tell the client to keep the head of the bed elevated at least 30°. Elevating the head of the bed prevents aspiration of the enteral formula, which is a priority in caring for a client with an NG tube. This action helps in reducing the risk of complications such as pneumonia. Choices A, C, and D are incorrect. While rinsing the feeding bag, ensuring the enteral formula temperature, and maintaining cleanliness are important aspects of enteral feeding care, the priority is to prevent aspiration by keeping the head of the bed elevated. These actions can be implemented after ensuring the client's safety by maintaining the correct bed position.
The LPN is instructing a client with high cholesterol about diet and lifestyle modifications. What comment from the client indicates that the teaching has been effective?
- A. If I exercise at least twice weekly for one hour, I will lower my cholesterol.
- B. I need to avoid eating proteins, including red meat.
- C. I will limit my intake of beef to 4 ounces per week.
- D. My blood level of low-density lipoproteins needs to increase.
Correct Answer: C
Rationale: The correct answer is C. Limiting intake of beef to 4 ounces per week is an effective dietary modification to manage high cholesterol. Choice A is incorrect because the frequency and duration of exercise alone may not be sufficient to lower cholesterol significantly. Choice B is incorrect as proteins, including lean sources like poultry and fish, can be a part of a healthy diet. Choice D is incorrect as low-density lipoproteins, known as bad cholesterol, should be decreased, not increased, for heart health.