Nokea
A client is preparing to administer an enema to a 64-year-old client. Which of the following actions of the nurse is most appropriate?
- A. Assist the client to lie in the semi-Fowler position
- B. Apply lubricating jelly to the tip of the catheter before insertion
- C. Instill a total of 30cc of fluid into the client's rectum
- D. Ask the client to hold the solution in for 30 seconds
Correct Answer: B
Rationale: When administering an enema to a client, the nurse should place the client in the Sims' position for easy access. The correct action is to apply lubricating jelly to the tip of the catheter before insertion to facilitate a smoother procedure. It is essential to instill a maximum of 750 to 1000 cc of fluid for an adult client, not just 30cc. Following administration, the nurse should ask the client to hold the solution for at least 5 minutes to allow for the desired effect of the enema. Therefore, choice B is the most appropriate action, as choices A, C, and D are incorrect due to inaccuracies in positioning, enema volume, and retention time.
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A nursing care plan states, 'Assist the patient to the bedside commode PRN.' When will this patient get this assistance to the commode?
- A. Whenever needed
- B. At bedtime
- C. During the night
- D. During the day
Correct Answer: A
Rationale: The correct answer is 'Whenever needed.' The abbreviation 'PRN' stands for 'pro re nata,' which translates to 'as needed' or 'whenever necessary.' This means that the patient will receive assistance to the commode whenever they require it, based on their individual needs and condition. Choices B, C, and D are incorrect because 'PRN' does not specify a specific time like bedtime, during the night, or during the day; instead, it indicates assistance based on the patient's needs.
A client is undergoing range of motion exercises, and the nurse moves the leg in a pattern of circumduction. Which movement is the nurse performing?
- A. Bending the leg at the knee
- B. Turning the foot inward and outward
- C. Moving the leg in a circle
- D. Moving the leg forward and up
Correct Answer: C
Rationale: Circumduction involves moving a limb in a circular pattern. In this scenario, the nurse is performing circumduction by moving the leg in a circular motion, engaging the muscles of the gluteus maximus and gluteus medius. Choice A, 'Bending the leg at the knee,' is incorrect as it describes flexion and extension movements. Choice B, 'Turning the foot inward and outward,' refers to inversion and eversion movements of the foot, not circumduction. Choice D, 'Moving the leg forward and up,' describes flexion and abduction movements, not circumduction.
When cleansing the genital area during perineal care, the nurse should _____________.
- A. cleanse the penis with a circular motion starting from the base and moving toward the tip.
- B. replace the foreskin after it has been pushed back to cleanse an uncircumcised penis.
- C. cleanse the rectal area first and then clean the patient's genital area.
- D. use the same area on the washcloth for each washing and rinsing stroke for a female resident.
Correct Answer: B
Rationale: During perineal care, when cleansing the genital area of an uncircumcised male patient, it is crucial to retract the foreskin to clean the area underneath. This helps in the removal of smegma, a substance that can accumulate and lead to bacterial growth and infection if not cleaned properly. The foreskin should then be replaced back to its original position after cleaning to ensure proper hygiene and prevent any potential complications. Choices A, C, and D are incorrect because they do not address the specific care required for an uncircumcised penis, which involves retracting and replacing the foreskin.
Which of the following statements best describes substance P?
- A. Substance P decreases a client's sensitivity to pain
- B. Substance P levels are drawn before administration of narcotic analgesics
- C. Substance P is found in the brain and is responsible for pain control and management of depression
- D. Substance P is found in the dorsal horn of the spinal column
Correct Answer: D
Rationale: Substance P is a neurotransmitter found in the brain and the dorsal horn of the spinal column, not just in the brain. It is associated with pain transmission and modulation. Substance P is known to cause inflammation, edema, and pain. While it plays a role in pain perception, it does not decrease a client's sensitivity to pain (Choice A), nor are its levels typically drawn before administering narcotic analgesics (Choice B). Although substance P is involved in pain control, it is not responsible for managing depression (Choice C). Therefore, the correct statement is that substance P is found in the dorsal horn of the spinal column.
A client is having difficulties reading an educational pamphlet. He cannot find his glasses. In order to read the words, he must hold the pamphlet at arm's length, which allows him to read the information. Which vision deficit does this client most likely suffer from?
- A. Cataracts
- B. Glaucoma
- C. Astigmatism
- D. Presbyopia
Correct Answer: D
Rationale: Presbyopia is a condition that occurs when the lens of the eye loses accommodation and is unable to focus light on objects nearby. As a result, clients are unable to see or read items up close but may have success when holding the same item at arm's length. Many clients with presbyopia must wear bifocals, but long-distance vision remains unaffected. Cataracts involve clouding of the eye's lens, leading to blurry vision. Glaucoma is associated with increased intraocular pressure that damages the optic nerve, causing vision loss. Astigmatism is a refractive error where the cornea or lens has an irregular shape, leading to distorted or blurred vision.