Nokea
A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath?
- A. Take measures to promote as much comfort as possible.
- B. Report any signs of drug addiction to the nurse immediately.
- C. Wait until the client's pain is gone before assisting with personal care.
- D. This client's pain will be difficult to manage, as the cause is unknown.
Correct Answer: A
Rationale: The correct instruction for the unlicensed assistive personnel (UAP) preparing to assist a client with intractable pain is to take measures to promote as much comfort as possible. Intractable pain is resistant to relief, so ensuring comfort during all activities, including a bed bath, is crucial to enhance the client's well-being and quality of care.
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A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?
- A. Plan low carbohydrate and high protein meals
- B. Engage in strenuous activity for an hour daily
- C. Keep a record of food and drinks consumed daily
- D. Participate in a group exercise class 3 times a week
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client is reviewing the signed operative consent with a nurse, who is admitted for the removal of a lipoma on the left leg. The client states that the consent form should say the removal of a lipoma on the right leg. Which intervention should the nurse implement?
- A. Notify the surgical team of the client's confusion
- B. Have the client sign a new surgical consent
- C. Add the correct leg information to the consent form
- D. Inform the surgeon about the client's concern
Correct Answer: D
Rationale: In this scenario, the nurse should inform the surgeon about the client's concern immediately. This is important to ensure that the correct procedure is performed on the intended leg. Communication with the surgeon is crucial to address any discrepancies in the consent form and prevent errors during the surgical procedure. Having the surgeon clarify and correct the consent form is essential to maintain patient safety and uphold the principles of informed consent.
A client in the early stages of Alzheimer's disease is very anxious and frequently asks about her deceased parents. Which intervention should the nurse implement to reduce the client's anxiety?
- A. Remind the client that her parents have passed away
- B. Ask the client about her favorite memories with her parents
- C. Engage the client in an activity to distract her from thinking about her parents
- D. Reorient the client to the present reality and surroundings
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During the suctioning of a tracheostomy tube, if the catheter appears to attach to the tracheal walls and creates a pulling sensation, what is the best action for the nurse to take?
- A. Release the suction by opening the vent.
- B. Continue suctioning to remove obstruction.
- C. Increase the pressure.
- D. Suction deeper.
Correct Answer: A
Rationale: When the catheter of the suctioning device attaches to the tracheal walls, causing a pulling sensation, the nurse should release the suction by opening the vent. This action will alleviate the pulling sensation and prevent trauma to the delicate tracheal walls. Continuing suctioning or applying more pressure can lead to tissue damage and should be avoided. Suctioning deeper can increase the risk of injuring the patient's airway.
The nurse is preparing a client for surgery. What action is most important for the nurse to take?
- A. Ensure that the client signs the consent form.
- B. Review the client's allergies with the surgical team.
- C. Confirm the client's identity using two identifiers.
- D. Verify that the surgical site is marked.
Correct Answer: A
Rationale: Ensuring that the client signs the consent form (A) is the most crucial action before surgery. The consent form is legally and ethically necessary for the procedure to proceed. While reviewing allergies (B), confirming identity (C), and verifying the surgical site (D) are essential steps, obtaining the client's informed consent takes precedence to protect the client's rights and ensure a safe surgical experience.