Nokea
A client is contemplating retirement and expresses uncertainty about wanting to retire. Which of the following responses should the nurse make?
- A. Let's talk about how the change in your job status will affect you.
- B. Have you considered the financial implications of retirement?
- C. What are your thoughts on retirement and how it may impact your life?
- D. Would you like to discuss potential activities you could engage in during retirement?
Correct Answer: A
Rationale: Choosing option A, 'Let's talk about how the change in your job status will affect you,' is the most appropriate response in this scenario. By discussing how retirement might affect the client, the nurse can address the client's concerns and emotions about the impending change. Option B, 'Have you considered the financial implications of retirement?' is not the best response as it focuses solely on financial aspects and does not address the client's emotional readiness for retirement. Option C, 'What are your thoughts on retirement and how it may impact your life?' is more open-ended and may not address the immediate concerns of the client expressing uncertainty. Option D, 'Would you like to discuss potential activities you could engage in during retirement?' assumes the client is certain about retiring and focuses on activities rather than addressing the client's feelings of uncertainty.
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A healthcare provider is delegating client care to assistive personnel. Which of the following tasks should the healthcare provider delegate?
- A. Evaluating healing of an incision
- B. Inserting an NG Tube
- C. Performing a simple dressing change
- D. Changing IV tubing
Correct Answer: C
Rationale: The correct task that a healthcare provider should delegate to assistive personnel is performing a simple dressing change. Assistive personnel are trained and competent in performing basic wound care activities like simple dressing changes. Evaluating the healing of an incision requires clinical judgment and assessment skills that are typically performed by licensed healthcare professionals, such as nurses or physicians. Inserting an NG tube and changing IV tubing involve invasive procedures that require specialized training and skills, making them tasks that should be performed by licensed healthcare providers rather than assistive personnel.
A client has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?
- A. Bladder scan shows 525 mL of urine
- B. Urine has a strong odor
- C. The client reports abdominal discomfort
- D. The catheter is blocked or not draining
Correct Answer: D
Rationale: The correct answer is D because if the catheter is blocked or not draining, it may need irrigation to restore proper flow. Option A, 'Bladder scan shows 525 mL of urine,' does not necessarily indicate the need for irrigation as it could be within the expected range for catheter drainage. Option B, 'Urine has a strong odor,' may indicate a urinary tract infection but does not directly correlate with the need for catheter irrigation. Option C, 'The client reports abdominal discomfort,' could indicate various issues but does not specifically suggest the need for catheter irrigation.
A client has a closed wound drainage system. Which of the following actions should the nurse take?
- A. Avoid pressing the container down to create a vacuum
- B. Wear sterile gloves while handling the drainage system
- C. Reset the container with the drainage port closed
- D. Maintain the drain in a dependent position to facilitate drainage
Correct Answer: D
Rationale: In a closed wound drainage system, it is essential to maintain the drain in a dependent position to allow for proper drainage. Gravity aids in the flow of drainage, preventing fluid backflow or pooling. Avoiding pressing the container down to create a vacuum (Choice A) is crucial as it can lead to complications in the system. Wearing sterile gloves (Choice B) is important for infection control when handling the drainage system. Resetting the container with the drainage port closed (Choice C) is incorrect as it can cause spillage and contamination of the surrounding area.
A child is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
- A. Administer analgesics to the child on a routine schedule throughout the day and night.
- B. Offer fluids to the child immediately after surgery.
- C. Allow the child to return to solid foods gradually.
- D. Avoid administering any medication until the child is fully awake.
Correct Answer: A
Rationale: Administering analgesics to the child on a routine schedule throughout the day and night is crucial for managing postoperative pain effectively and ensuring the child's comfort. Pain management is a priority in the postoperative period to promote healing and prevent complications. Offering fluids to the child immediately after surgery (Choice B) is essential to prevent dehydration, but pain control takes precedence. Allowing the child to return to solid foods gradually (Choice C) is important, but initially, the child may need to start with clear liquids and progress to soft foods post-tonsillectomy. Avoiding administering any medication until the child is fully awake (Choice D) is not advisable because timely pain relief is essential for the child's comfort and recovery.
When teaching the guardian of a 12-year-old male client about manifestations of puberty, which of the following physical changes typically occurs first?
- A. Appearance of downy hair on the upper lip
- B. Hair growth in the axillae
- C. Enlargement of the testes and scrotum
- D. Deepening of the voice
Correct Answer: C
Rationale: During puberty in males, the first physical change that typically occurs is the enlargement of the testes and scrotum. This change is due to increased production of testosterone, which stimulates growth and development of the genital organs. The appearance of downy hair on the upper lip (Choice A) and hair growth in the axillae (Choice B) usually follow the enlargement of the testes and scrotum. Deepening of the voice (Choice D) is a later stage change that occurs during puberty as the larynx (voice box) grows and the vocal cords lengthen and thicken.