Nokea
A client is talking with an older adult who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I'm not sure I want 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. You should consider how retirement will affect your financial situation.
- C. Retirement is a big change, take your time to decide.
- D. Have you thought about what you will do after you retire?
Correct Answer: A
Rationale: The correct response is to discuss how the change in job status will affect the client. This helps the client consider the emotional and psychological impact of retirement. Choice B focuses solely on the financial aspect of retirement, which may not address the client's current concerns about enjoying their job. Choice C acknowledges the decision-making process but does not actively engage the client in exploring their feelings. Choice D shifts the focus to post-retirement plans without addressing the client's current hesitation about retiring.
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Which task can the RN delegate to an unlicensed assistive personnel (UAP)?
- A. Take a history on a newly admitted client
- B. Adjust the rate of a gastric tube feeding
- C. Check the blood pressure of a 2-hour postoperative client
- D. Check on a client receiving chemotherapy
Correct Answer: C
Rationale: The correct answer is C. Checking the blood pressure of a 2-hour postoperative client is a task that can be safely delegated to an unlicensed assistive personnel (UAP) as it falls within their scope of practice. This task is routine and does not require specialized nursing knowledge or critical decision-making. Options A, B, and D involve tasks that require a higher level of training and critical thinking beyond the scope of a UAP. Taking a history, adjusting tube feeding rates, and monitoring a client receiving chemotherapy are responsibilities that should be performed by licensed healthcare providers who have the necessary skills and training.
A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy?
- A. Collaborating with providers to perform obesity screenings during routine office visits.
- B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity.
- C. Providing specialized intraoperative training in surgical treatments for obesity.
- D. Educating acute care nurses about postoperative complications related to obesity.
Correct Answer: A
Rationale: The correct answer is A: Collaborating with providers to perform obesity screenings during routine office visits. This is a primary health care strategy as it focuses on prevention and early detection, which are key components of managing obesity. Screening during routine visits allows for timely identification of obesity and related health risks, enabling early intervention. Choices B, C, and D do not align with primary health care strategies for obesity. Ensuring availability of specialized beds, providing intraoperative training, and educating about postoperative complications are more focused on secondary and tertiary levels of care, rather than primary prevention and early detection.
A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, 'You are not putting that hose down my throat.' Which of the following statements should the nurse make?
- A. 'I can see that this is upsetting you.'
- B. 'It is necessary for your treatment.'
- C. 'It will be over quickly, and you will feel better.'
- D. 'Let me explain again why this procedure is important.'
Correct Answer: A
Rationale: In this situation, the nurse should acknowledge the client's feelings by stating, 'I can see that this is upsetting you.' This response validates the client's emotions and demonstrates empathy, which can help build trust and rapport. Choice B is too direct and might not address the client's emotional state. Choice C focuses on the outcome rather than the client's current distress. Choice D does not directly address the client's feelings of distress and may not effectively alleviate their anxiety.
A healthcare professional is providing care to a client who has a tracheostomy. Which of the following actions should the professional take to prevent complications?
- A. Clean around the stoma with povidone-iodine.
- B. Maintain sterile technique when performing tracheostomy care.
- C. Use clean technique when suctioning the tracheostomy.
- D. Change tracheostomy ties weekly.
Correct Answer: B
Rationale: Maintaining sterile technique when performing tracheostomy care is essential in preventing infections and complications. Option A is incorrect because povidone-iodine may be too harsh for cleaning around the stoma and can lead to skin irritation. Option C is incorrect because suctioning a tracheostomy should be done using sterile technique to minimize the risk of introducing pathogens. Option D is incorrect as tracheostomy ties need to be changed more frequently, usually every 1-2 days, to prevent skin breakdown and infection.
A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicated understanding?
- A. "I will set my water heater at 130°F."
- B. "Once my baby can sit up, they should be safe in the bathtub."
- C. "I will place my baby on their stomach to sleep."
- D. "Once my infant starts to push up, I will remove the mobile from over the crib."
Correct Answer: D
Rationale: The correct answer is D. Removing the mobile when the baby starts to push up prevents choking hazards as infants can reach and grab objects posing a risk of choking. Choice A is unsafe as setting the water heater at 130°F can scald a child. Choice B is incorrect because even when a baby can sit up, they still require close supervision in the bathtub. Choice C is unsafe as current guidelines recommend placing babies on their backs to sleep to reduce the risk of sudden infant death syndrome (SIDS). Therefore, choices A, B, and C are incorrect or unsafe practices for infant care.