Nokea
A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?
- A. Allow the client to melt ice chips in the mouth
- B. Provide mints to freshen the breath
- C. Perform frequent oral care with a tooth sponge
- D. Swab the mouth with glycerin swabs
Correct Answer: C
Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this scenario. This helps maintain comfort and prevent dryness in clients with nasogastric tubes. Allowing the client to melt ice chips in the mouth may not address oral care needs effectively. Providing mints to freshen the breath is not the priority when the client needs oral care. Swabbing the mouth with glycerin swabs may not be as effective as performing thorough oral care with a tooth sponge.
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A client with hypertension is prescribed a thiazide diuretic. What dietary recommendation should the nurse make?
- A. Encourage a diet low in carbohydrates and fats.
- B. Avoid foods high in vitamin K, such as spinach and kale.
- C. Increase salt intake to prevent dehydration.
- D. Eat potassium-rich foods like bananas and oranges.
Correct Answer: D
Rationale: The correct answer is D: 'Eat potassium-rich foods like bananas and oranges.' Thiazide diuretics can lead to potassium loss, so it is essential for clients to consume potassium-rich foods to maintain adequate levels. Choice A is incorrect because focusing solely on low carbohydrates and fats does not address the specific issue of potassium loss. Choice B is unrelated as vitamin K content is not a concern with thiazide diuretics. Choice C is incorrect as increasing salt intake would exacerbate hypertension and not prevent dehydration.
The nurse is providing care for a client with advanced liver disease who is experiencing ascites. Which intervention should the nurse implement to help manage the client's fluid volume?
- A. Increase the client's sodium intake
- B. Encourage the client to drink more fluids
- C. Place the client in a supine position
- D. Administer a diuretic as prescribed
Correct Answer: D
Rationale: Administering a diuretic as prescribed is the most appropriate intervention to manage fluid volume in a client with ascites due to advanced liver disease. Diuretics help reduce fluid accumulation in the body, including the abdominal cavity where ascites occurs. Increasing sodium intake would worsen fluid retention, and encouraging more fluid intake can exacerbate ascites. Placing the client in a supine position does not directly address the fluid volume issue associated with ascites.
A client tells the nurse, 'I have something very important to tell you if you promise not to tell.' The best response by the nurse is
- A. I must document and report any information.
- B. I can't make such a promise.
- C. That depends on what you tell me.
- D. I must report everything to the treatment team.
Correct Answer: B
Rationale: The correct answer is B because the nurse cannot promise confidentiality in this context. It is essential to prioritize the safety and well-being of the client and others. Certain information, such as harm to oneself or others, must be reported to ensure appropriate interventions are taken. Choice A is incorrect because while documentation is important, confidentiality cannot be guaranteed in this situation. Choice C is incorrect as the nurse should not make promises that may conflict with their professional responsibilities. Choice D is incorrect as reporting everything to the treatment team without discretion may breach client confidentiality.
A client with multiple sclerosis is experiencing fatigue. What is the nurse's priority intervention?
- A. Encourage the client to increase physical activity.
- B. Encourage the client to take rest breaks during activities.
- C. Administer a stimulant medication to reduce fatigue.
- D. Advise the client to use energy conservation techniques.
Correct Answer: D
Rationale: The correct answer is D: Advise the client to use energy conservation techniques. Energy conservation techniques are crucial in managing fatigue in multiple sclerosis. These techniques involve prioritizing activities, pacing oneself, and taking rest breaks to prevent overexertion, which can exacerbate fatigue. Encouraging the client to increase physical activity (choice A) may worsen fatigue if not done with proper energy conservation. Taking rest breaks during activities (choice B) is important but falls secondary to teaching energy conservation techniques. Administering a stimulant medication to reduce fatigue (choice C) should not be the priority as non-pharmacological interventions like energy conservation should be attempted first.
A client in labor is experiencing late decelerations in fetal heart rate. What intervention should the nurse perform first?
- A. Reposition the client onto her left side.
- B. Apply oxygen via nasal cannula.
- C. Prepare for an emergency cesarean section.
- D. Increase IV fluid administration to improve perfusion.
Correct Answer: A
Rationale: Late decelerations indicate fetal distress due to compromised placental perfusion. Repositioning the client onto her left side is the priority intervention as it can increase blood flow to the placenta, improving fetal oxygenation. Applying oxygen via nasal cannula (choice B) can be the next step after repositioning if late decelerations persist. Emergency cesarean section (choice C) is not the initial action for late decelerations unless other interventions are ineffective. Increasing IV fluid administration (choice D) is not the first-line intervention for late decelerations; repositioning takes precedence to address the underlying cause.