Nokea
A client is evaluated by a nurse regarding the use of a sequential compression device. Which of the following client statements indicates understanding of the device's purpose?
- A. "This device will keep me from developing skin sores."
- B. "This device will keep the blood circulating in my leg."
- C. "This device will prevent my leg muscles from weakening."
- D. "This device will maintain the health of my joints."
Correct Answer: B
Rationale: The correct answer is B because sequential compression devices are utilized to enhance circulation and prevent clot formation in the legs. Option A is incorrect because these devices are not primarily meant to prevent skin sores. Option C is incorrect because the devices do not directly address muscle weakness. Option D is incorrect as the main purpose of sequential compression devices is not related to joint health.
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The patient is being taught about flossing and oral hygiene. What instruction will the nurse include in the teaching session?
- A. Using waxed floss helps prevent bleeding
- B. Flossing removes plaque and tartar from the teeth
- C. Flossing at least 3 times a day is beneficial
- D. Applying toothpaste before flossing is harmful
Correct Answer: B
Rationale: The correct answer is B. Flossing is essential for removing plaque and tartar between teeth, contributing to better oral hygiene. Choice A is not entirely accurate as waxed floss may not solely prevent bleeding. Flossing three times a day, as mentioned in choice C, can be excessive and unnecessary, while choice D is incorrect as applying toothpaste before flossing is not harmful but might not provide additional benefits.
A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement?
- A. Evaluate the stool samples for the presence of blood
- B. Assess for the presence of an impaction
- C. Determine which home remedies were used
- D. Obtain a list of prescribed medications
Correct Answer: B
Rationale: Assessing for impaction is crucial as it is a common cause of constipation and abdominal discomfort. In this scenario, the patient's symptoms of chronic constipation and no bowel movement for five days despite trying home remedies indicate a potential impaction that needs to be assessed. Evaluating stool samples for blood, determining the home remedies used, or obtaining a list of prescribed medications, while potentially relevant, are not as urgent as assessing for impaction in this situation.
While being educated by a nurse, an assistive personnel (AP) is learning about proper hand hygiene. Which statement made by the AP indicates a good understanding of the teaching?
- A. There are times I should use soap and water rather than alcohol-based hand rub to clean my hands.
- B. I can use alcohol-based hand rub after using the restroom.
- C. Soap and water are only necessary if my hands are visibly dirty.
- D. Hand rub is always sufficient, regardless of the situation.
Correct Answer: C
Rationale: Choice C is the correct answer because it demonstrates an understanding that soap and water should be used when hands are visibly dirty or when dealing with specific pathogens. Choice A is incorrect because it suggests the use of soap and water over alcohol-based hand rub without specifying the circumstances. Choice B is incorrect as it implies that using alcohol-based hand rub after using the restroom is always suitable. Choice D is incorrect because it states that hand rub is always enough, which is not true when hands are visibly soiled or when specific pathogens are present.
During a client admission, how should the nurse conduct medication reconciliation?
- A. Compare the client's home medications to the provider's prescriptions.
- B. Review the client's medical history.
- C. Assess the client's current medications.
- D. Ask the client about their allergies.
Correct Answer: A
Rationale: During medication reconciliation, the nurse should compare the client's home medications with the provider's prescriptions to ensure accuracy and prevent medication errors. Reviewing the client's medical history (Choice B) is important but not the primary focus of medication reconciliation. Assessing the client's current medications (Choice C) is also vital but is not specific to the comparison between home and prescribed medications during reconciliation. Asking the client about their allergies (Choice D) is relevant for ensuring safe medication administration but is not the primary step in medication reconciliation, which involves comparing actual medications.
A client with a terminal illness is expected to pass away within 24 hours. The family asks the nurse about what to expect at this time. Which of the following findings should the nurse include?
- A. Regular breathing pattern
- B. Warm extremities
- C. Increased urine output
- D. Decreased muscle tone
Correct Answer: D
Rationale: As death approaches, decreased muscle tone and other signs like decreased blood pressure, irregular breathing patterns, cold extremities, and decreased urine output are common. Warm extremities (choice B) would not be expected as circulation may be compromised. Increased urine output (choice C) is unlikely as organ function declines. A regular breathing pattern (choice A) is also unlikely as irregular breathing patterns are common near death.