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A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?
- A. Offer fruit juice at least twice during both the day and evening shifts.
- B. Encourage the client to eat all of the meals that are sent.
- C. Lower the bed prior to helping the client to move up in bed.
- D. Have the client hold a pillow over the abdomen to cough and deep breathe.
Correct Answer: D
Rationale: Splinting aids breathing.
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A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?
- A. I'm sorry, but your sibling's medical information is none of your business.
- B. I can give you those results as soon as I get them back from the lab.
- C. I can only give medical information to the client with an approved interpreter.
- D. The healthcare provider will share this information with you.
Correct Answer: C
Rationale: Approved interpreter ensures confidentiality.
The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?
- A. Print the electronic medical record (EMR) from a backup server.
- B. Identify information as a late entry in the record.
- C. Wait for notification that the system has been rebooted.
- D. Notify the information services department of the situation.
Correct Answer: D
Rationale: Notifying IT resolves system issues promptly.
When interviewing a client about sexuality/reproductive function, which is the best approach for the nurse to use?
- A. Get the most difficult questions over with first.
- B. Begin with questions that are less sensitive in nature.
- C. Ask questions in a vague, non-specific format.
- D. Share personal values to put the client at ease.
Correct Answer: B
Rationale: Less sensitive questions build rapport.
A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 0 to 10. After placing a call to the healthcare provider, which action should the nurse implement?
- A. Provide at least 20 minutes of back massage and gentle efleurage.
- B. Instruct the client to use guided imagery and slow rhythmic breathing.
- C. Place a hot water circulation device, such as an aquathermia pad, on the operative site.
- D. Tune to a television show or easy listening music to provide distraction.
Correct Answer: A
Rationale: Massage complements pain management.
The nurse receives a report that a patient with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?
- A. Give the patient 8 ounces (240 mL) of water to drink.
- B. Notify the healthcare provider.
- C. Check the drainage tubing for a kink.
- D. Review the intake and output record.
Correct Answer: C
Rationale: Checking tubing addresses potential obstruction.