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A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client?
- A. Posting swallowing precautions at the head of the client's bed.
- B. Noting changes in the treatment plan in the client's medical record.
- C. Recording the client's progress in the nurses' notes.
- D. Having interdisciplinary team meetings for the client on a regular basis.
Correct Answer: D
Rationale: The correct answer is D: Having interdisciplinary team meetings for the client on a regular basis. This promotes communication among staff by ensuring that all team members involved in the client's care are updated on the client's condition, progress, and treatment plan. It allows for collaboration and coordination of care, leading to better outcomes for the client. Posting swallowing precautions (A) only addresses one aspect of care and does not promote overall communication among staff. Noting changes in the treatment plan (B) and recording progress in nurses' notes (C) are essential but do not facilitate direct communication among staff. Interdisciplinary team meetings (D) involve direct communication, discussion, and collaboration among team members, making it the best option.
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A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
- A. Check the client for injuries.
- B. Move hazardous objects away from the client.
- C. Notify the provider.
- D. Ask the client to describe how she felt prior to the fall.
Correct Answer: A
Rationale: The correct answer is A: Check the client for injuries. This should be the first action taken because the nurse needs to assess the client's immediate physical condition to determine if there are any life-threatening injuries that require immediate attention. Moving hazardous objects (B) can wait until after ensuring the client's safety. Notifying the provider (C) can also be done after assessing the client's condition. Asking the client about how she felt prior to the fall (D) is important but not as urgent as checking for injuries.
A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
- A. I will wait 15 minutes after drinking coffee to measure my blood pressure.
- B. I will measure my blood pressure while my arm is elevated above my heart.
- C. I should remove constrictive clothing prior to measuring my blood pressure.
- D. I should measure my blood pressure immediately after eating breakfast.
Correct Answer: C
Rationale: The correct answer is C because removing constrictive clothing prior to measuring blood pressure helps ensure accurate readings. Tight clothing can artificially elevate blood pressure readings. Choice A is incorrect because waiting 15 minutes after drinking coffee doesn't impact blood pressure measurement accuracy. Choice B is incorrect because the arm should be at heart level, not elevated. Choice D is incorrect because blood pressure should be measured on an empty stomach for consistency.
A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?
- A. Most people who have this procedure feel better following the treatment.'
- B. Your doctor wouldn't have ordered this treatment unless it was necessary.'
- C. It's okay to be nervous before this treatment.'
- D. You don't have to go through with the treatment.'
Correct Answer: D
Rationale: Correct Answer: D. "You don't have to go through with the treatment."
Rationale: This response respects the client's autonomy and right to make decisions about their own healthcare. It acknowledges the client's change of mind and supports their decision-making process without pressuring them. It is important for healthcare providers to prioritize patient autonomy and respect their choices.
Other Choices:
A: Incorrect. This statement may invalidate the client's feelings and pressure them to proceed with the treatment.
B: Incorrect. This statement undermines the client's autonomy by implying that the doctor's decision is more important than the client's own preferences.
C: Incorrect. While acknowledging nervousness is appropriate, it does not address the client's change of mind and decision to not proceed with the treatment.
A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.)
- A. Lacrimal apparatus
- B. Pupil clarity
- C. Appearance of bulbar conjunctivae
- D. Visual fields
- E. Visual acuity
Correct Answer: B,C,D,E
Rationale: The correct assessments for identifying an older adult client's safety needs are B, C, D, and E. Pupil clarity is crucial for detecting any visual impairments that may increase fall risk. The appearance of bulbar conjunctivae can indicate underlying eye conditions affecting vision and balance. Assessing visual fields helps identify potential blind spots that may contribute to falls. Visual acuity is essential for clear vision and spatial awareness, both critical for preventing falls. Choices A and F have no direct relevance to assessing fall risk in older adults, making them incorrect options.
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
- A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
- B. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min
- C. Make sure the reservoir bag of a partial rebreathing mask remains deflated.
- D. Use petroleum jelly to lubricate the client's nares, face, and lips.
Correct Answer: B
Rationale: The correct answer is B: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. This is the correct action because excessive oxygen flow can lead to oxygen toxicity and respiratory depression in patients. Nasal cannulas are commonly used for oxygen therapy and a flow rate of more than 6 L/min can cause discomfort and dryness of the nasal passages. It is important to adhere to evidence-based practice guidelines to ensure patient safety and well-being.
Choice A is incorrect because aligning the flow rate with the top of the ball inside the flow meter is not a reliable method for regulating oxygen flow. Choice C is incorrect as the reservoir bag of a partial rebreathing mask should remain inflated to ensure an adequate oxygen supply. Choice D is incorrect as petroleum jelly should not be used in oxygen therapy due to the risk of flammability.