Nokea
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?
- A. Autopsy of the body is prohibited.
- B. Blood transfusions are forbidden.
- C. Alcohol use in any form is not allowed.
- D. A vegetarian diet must be followed.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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When assisting a client with right-sided hemiplegia to get into a wheelchair, how should the nurse position the wheelchair?
- A. On the left side of the bed facing the foot of the bed.
- B. On the right side of the bed facing the head of the bed.
- C. Perpendicular to the bed on the right side.
- D. Facing the bed on the left side of the bed.
Correct Answer: A
Rationale: Positioning the wheelchair on the left side of the bed facing the foot of the bed is the correct approach when assisting a client with right-sided hemiplegia. Placing the wheelchair on the left side allows the client to stand on their unaffected foot and pivot to sit down safely. This positioning facilitates a smoother transfer and helps maintain the client's stability during the process.
When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next?
- A. Place a sterile drape under the client's buttocks.
- B. Instruct the client to inhale and then exhale slowly.
- C. Discard the gloves and apply new sterile gloves.
- D. Apply a sterile lubricant to the end of the catheter.
Correct Answer: D
Rationale: After testing the catheter balloon for patency, the nurse should proceed to apply a sterile lubricant to the end of the catheter. This lubrication helps facilitate the insertion of the catheter smoothly. Placing a sterile drape under the client's buttocks should have been done prior to this step. Discarding the gloves and applying new sterile gloves is not necessary at this point in the procedure. Instructing the client to inhale and exhale slowly is not part of the immediate steps for inserting an indwelling urinary catheter.
The healthcare provider is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?
- A. A college-age track runner with a sprained ankle.
- B. A lactating woman nursing her 3-day-old infant.
- C. A school-aged child with Type 2 diabetes.
- D. An elderly man being treated for a peptic ulcer.
Correct Answer: B
Rationale: A lactating woman (B) has the greatest need for additional protein intake. Lactation increases the metabolic demands for protein to support milk production, making it essential for the mother to have a higher protein intake. While clients in choices A, C, and D also require protein for various reasons, they do not have the same increased protein demands as a lactating woman.
The healthcare provider identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection?
- A. Administration of plasma expanders
- B. Use of careful handwashing technique
- C. Application of a topical antibacterial cream
- D. Limiting visitors to the client with burns
Correct Answer: B
Rationale: Proper handwashing technique is crucial in preventing the transmission of infections, especially in clients with burns where the risk of infection is high. It is the most effective intervention to reduce the risk of contamination and promote healing in these clients. While plasma expanders, topical antibacterial creams, and visitor restrictions are important considerations in burn care, meticulous hand hygiene takes precedence in preventing infections.
A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?
- A. Ask him to rate his pain on a scale of 1 to 10.
- B. Encourage him to wait until bedtime so the pill can help him sleep.
- C. Attend to an acutely ill client's needs first because this client is laughing.
- D. Instruct him in the use of deep breathing exercises for pain control.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.