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A client is scheduled for hip surgery in an hour. Which of the following actions is the nurse's priority?
- A. Ensure that the client signs the consent form.
- B. Lock the client's valuables in a secure location.
- C. Verify the client's lab values in the medical record.
- D. Administer the prescribed preoperative sedative.
Correct Answer: A
Rationale: The nurse's priority is to ensure that the client signs the consent form before the hip surgery. This is crucial as it ensures that the client has provided informed consent for the procedure. Locking valuables, verifying lab values, and administering sedatives are important tasks but ensuring consent takes precedence as it directly impacts the client's right to make decisions about their care.
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A client reports abdominal pain. An assessment by the nurse reveals a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?
- A. Temperature
- B. Heart rate
- C. Abdominal tenderness
- D. Overdue menses
Correct Answer: A
Rationale: The nurse's priority should be the client's temperature. A high temperature of 39.2 degrees C (102 degrees F) indicates a potential infection or inflammation that requires immediate attention. While heart rate and abdominal tenderness are important assessments, the temperature takes precedence as it signals a more urgent issue. Overdue menses, although significant, are not the priority in this scenario when compared to the possibility of an acute infection or inflammatory process.
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the LPN/LVN to take?
- A. Record the coughing incident. No further action is required at this time.
- B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
- C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
- D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
Correct Answer: C
Rationale: After a client experiences severe coughing following nasogastric tube feedings, it is crucial to verify proper tube placement. Checking the pH of fluid withdrawn from the tube helps confirm the tube's correct positioning. Option A is incorrect because further action is necessary to ensure the client's safety. Option B is inappropriate as it suggests stopping the feeding without assessing the tube's placement. Option D is incorrect as injecting air into the tube may lead to further complications if the tube is not positioned correctly.
A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority?
- A. "I kind of like this boy in my class, but he doesn't like me back."
- B. "I want to hang out with the kids in the science club, but the jocks pick on them."
- C. "I am so fat, I skip meals to try to lose weight."
- D. "My dad wants me to be a lawyer like him, but I just want to dance."
Correct Answer: C
Rationale: The correct answer is C. Skipping meals to lose weight may indicate an eating disorder or significant distress, which can have serious health implications. This behavior raises concerns about the adolescent's physical and mental well-being. The nurse should prioritize addressing potential eating disorders and body image issues in this situation. Choices A, B, and D, while important, do not pose an immediate risk to the adolescent's health or well-being compared to the potential consequences of disordered eating behavior.
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?
- A. Sit on the toilet 30 minutes after eating a meal.
- B. Increase your fluid intake to help with bowel movements.
- C. Exercise regularly to improve bowel function.
- D. Consume more high-fiber foods to prevent constipation.
Correct Answer: A
Rationale: The correct statement the nurse should include in the teaching is to 'Sit on the toilet 30 minutes after eating a meal.' This advice can help establish a regular bowel routine and improve bowel movement. Option B, 'Increase your fluid intake to help with bowel movements,' while important, is not specific to the time after eating and does not directly address the need for establishing a routine. Option C, 'Exercise regularly to improve bowel function,' is also important but does not address the timing of bowel movements. Option D, 'Consume more high-fiber foods to prevent constipation,' is beneficial for preventing constipation but does not address the timing aspect related to bowel movements.
Which of the following should a group of community health nurses plan as part of a primary prevention program for occupational pulmonary diseases?
- A. Screening for early symptoms
- B. Providing treatment for diagnosed conditions
- C. Elimination of the exposure
- D. Increasing awareness of symptoms
Correct Answer: C
Rationale: The correct answer is C: 'Elimination of the exposure.' Primary prevention programs for occupational pulmonary diseases aim to prevent the development of these diseases by eliminating or minimizing exposure to harmful substances in the workplace. Screening for early symptoms (Choice A) focuses on secondary prevention, detecting diseases at an early stage. Providing treatment for diagnosed conditions (Choice B) is part of tertiary prevention, managing and treating established diseases. Increasing awareness of symptoms (Choice D) may help in early detection but does not directly address the prevention of exposure, which is crucial for primary prevention of occupational pulmonary diseases.