Nokea
A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?
- A. Evacuate the client
- B. Attempt to extinguish the fire
- C. Call the fire department
- D. Close the door to contain the fire
Correct Answer: A
Rationale: The correct answer is to Evacuate the client (Choice A). In the event of a fire, the safety of the client is the top priority. The RACE (Rescue, Alarm, Contain, Extinguish) mnemonic is used in fire emergencies. The first step is to Rescue or Evacuate the individual from immediate danger. Attempting to extinguish the fire (Choice B) may endanger both the client and the nurse. Calling the fire department (Choice C) is important but should come after ensuring the client's safety. Closing the door to contain the fire (Choice D) is not appropriate in this scenario because the priority is to remove the client from harm's way.
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A client with cardiovascular disease is being taught by a nurse how to reduce sodium and cholesterol intake. The nurse understands that the most significant factor in planning dietary changes for this client is:
- A. Client's financial resources
- B. Involvement of the client in planning the change
- C. Availability of low-sodium foods
- D. Frequency of dietary counseling sessions
Correct Answer: B
Rationale: The most significant factor in planning dietary changes for a client with cardiovascular disease is the involvement of the client in planning the change. By involving the client in the planning process, the nurse ensures that the client takes ownership of their health and is more likely to adhere to and succeed in modifying dietary habits. This empowerment and engagement enhance the client's motivation and commitment to making sustainable changes. Financial resources, availability of low-sodium foods, and frequency of dietary counseling sessions are important considerations but are not as crucial as the client's active involvement in the planning process.
The client with a diagnosis of chronic heart failure is receiving discharge teaching. Which statement by the client indicates a need for further teaching?
- A. I will weigh myself every day at the same time.
- B. I will call my doctor if my legs swell more.
- C. I will take my water pill only when I feel short of breath.
- D. I will limit the amount of salt in my diet.
Correct Answer: C
Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to help manage fluid retention in chronic heart failure. This statement indicates a need for further teaching as the client needs to understand the importance of consistent medication adherence. Choices A, B, and D demonstrate good understanding of self-care management in heart failure, including daily weight monitoring, prompt reporting of worsening symptoms to the healthcare provider, and dietary sodium restriction, respectively.
A nurse is caring for a group of clients. How should the nurse prevent the spread of infection?
- A. Place a client with TB in a negative pressure room.
- B. Use standard precautions only.
- C. Place a client with TB in a private room.
- D. Use barrier precautions only.
Correct Answer: A
Rationale: The correct answer is to place a client with TB in a negative pressure room. Tuberculosis (TB) is an airborne infectious disease, and placing the client in a negative pressure room helps prevent the spread of the infection by containing and filtering the air within the room. Standard precautions (Choice B) are important for preventing the spread of infection in general, but specific precautions are needed for airborne diseases like TB. Placing the client in a private room (Choice C) may not provide adequate ventilation and containment of airborne pathogens. Using barrier precautions (Choice D) alone is not sufficient for preventing the airborne transmission of TB.
A client reports constipation, and a nurse is providing dietary teaching. Which of the following foods should the nurse recommend?
- A. Macaroni and cheese
- B. One medium apple with skin
- C. One cup of plain yogurt
- D. Roast chicken and white rice
Correct Answer: B
Rationale: The correct answer is B: One medium apple with skin. Foods high in fiber, like apples with skin, are recommended to relieve constipation due to their fiber content, which aids in bowel regularity. Macaroni and cheese, yogurt, and roast chicken with white rice do not provide as much fiber and are less effective in alleviating constipation. While yogurt can sometimes contain probiotics that support gut health, it is not as effective in treating constipation as high-fiber foods like apples.
A charge nurse is assigning tasks to a nurse and assistive personnel for a group of clients. Which of the following tasks should the charge nurse delegate to the AP?
- A. Report ABG results to the provider
- B. Instruct a client about how to use an incentive spirometer
- C. Administer an enteral feeding to a client who has an established gastrostomy tube
- D. Monitor the color of a client's urinary output
Correct Answer: D
Rationale: The correct answer is D because monitoring the color of a client's urinary output is a task that can be safely delegated to assistive personnel. This task involves basic observation and does not require specialized nursing knowledge or skills. Choice A is incorrect because reporting ABG results to the provider requires interpretation and critical thinking skills typically performed by a nurse. Choice B is incorrect as instructing a client about how to use an incentive spirometer involves educating and assessing the client, which is a nursing responsibility. Choice C is incorrect as administering enteral feeding to a client with a gastrostomy tube requires nursing expertise to ensure proper technique and monitoring for complications.