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A nurse is reinforcing teaching with a client who has a new diagnosis of heart failure. Which of the following tools should the nurse use when speaking with client?
- A. Materials should be culturally diverse.
- B. Information must be accurate and current.
- C. Materials should be written at the eighth-grade level.
- D. Materials should be written in the client's spoken language.
- E. Materials should be distributed to the client in advance.
Correct Answer: A,B,C,D
Rationale: The correct tools for teaching a client with heart failure diagnosis are A, B, C, and D. A: Culturally diverse materials ensure inclusivity and relevance. B: Accurate and current information enhances understanding and compliance. C: Eighth-grade level ensures clarity and simplicity. D: Using the client's spoken language promotes comprehension. These tools cater to different learning needs and facilitate effective communication. Other options like distributing materials in advance (E) may not address immediate questions or concerns.
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A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?
- A. Position the client supine.
- B. Have the client bear down during removal.
- C. Cleanse the perineal area with an antiseptic.
- D. Deflate the balloon halfway and then pull out the catheter.
Correct Answer: A
Rationale: The correct answer is A: Position the client supine. This position allows for easier access to the urinary catheter and minimizes the risk of spillage or contamination. Supine position also provides better comfort and stability for the client during the catheter removal process.
Summary of other choices:
B: Having the client bear down during removal can increase the risk of injury and discomfort.
C: Cleaning the perineal area with an antiseptic is important but should be done after removing the catheter.
D: Deflating the balloon halfway and pulling out the catheter can cause pain and discomfort for the client and may lead to trauma.
A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take?
- A. Collect urine from the catheter's port.
- B. Use a sterile specimen container.
- C. Use sterile water to inflate the balloon.
- D. Instruct the client to clean from front to back with an antiseptic solution.
Correct Answer: B
Rationale: The correct answer is B: Use a sterile specimen container. This is crucial to prevent contamination of the urine sample, ensuring accurate culture and sensitivity results. Sterile container minimizes the risk of introducing bacteria from the environment. Option A is incorrect because collecting urine from the catheter's port may introduce contaminants. Option C is incorrect as sterile water is not used to inflate the balloon but rather sterile saline. Option D is incorrect because cleaning from front to back is not relevant to obtaining a urine specimen via catheterization.
A nurse is reinforcing discharge teaching with a client who has a new diagnosis of a latex allergy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply an elastic bandage to a cut.
- B. When cleaning, I like to use dishwashing gloves.
- C. On my son's birthday I plan to buy balloons.
- D. I will use ink pens for writing.
Correct Answer: D
Rationale: The correct answer is D: "I will use ink pens for writing." This statement indicates an understanding of the teaching because ink pens do not contain latex, thus reducing the risk of exposure for someone with a latex allergy. Elastic bandages (choice A) typically contain latex, dishwashing gloves (choice B) may contain latex, and balloons (choice C) are commonly made of latex, all of which could trigger an allergic reaction. Therefore, using ink pens for writing is the safest choice to avoid latex exposure.
A nurse is reinforcing teaching with a 40-year-old female client about preventive health screenings. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should have my skin checked every 5 years for cancer.
- B. I will need to have a mammogram every year now.
- C. I should have my first colonoscopy when I turn 65.
- D. I will be checked for uterine cancer every 2 years.
Correct Answer: B
Rationale: The correct answer is B: "I will need to have a mammogram every year now." Mammograms are recommended for women starting at age 40 to screen for breast cancer. Annual mammograms help detect any abnormalities early, improving the chances of successful treatment. Choice A is incorrect as skin checks should be done annually. Choice C is incorrect as the first colonoscopy is usually recommended at age 50. Choice D is incorrect as there is no standard screening for uterine cancer every 2 years.
A nurse is reinforcing preoperative teaching with a client of Chinese heritage who speaks limited English. Which of the following methods of communication by the nurse demonstrates cultural competence?
- A. Incorporate humor in the teaching with the client.
- B. Address the client by her last name.
- C. Maintain direct eye contact with the client.
- D. Place a hand on the client's head.
Correct Answer: B
Rationale: Addressing the client formally by her last name shows respect, which aligns with many cultural norms in Chinese heritage.