Nokea
A client with liver failure and ascites is having a paracentesis to relieve severe dyspnea resulting from abdominal fluid accumulation. Prior to the procedure, the nurse assists the client to urinate. Which of the following is the most important reason to have the patient urinate?
- A. Patient comfort
- B. Prevention of incontinence
- C. Prevention of bladder puncture
- D. Fluid displacement
Correct Answer: C
Rationale: Urinating before paracentesis prevents bladder puncture (C) by emptying the bladder, reducing risk during needle insertion.
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An adolescent client hospitalized with anorexia nervosa is described by her parents as 'the perfect child.' When planning care for the client, the nurse should:
- A. Allow her to choose what foods she will eat
- B. Provide activities to foster her self-identity
- C. Encourage her to participate in morning exercise
- D. Provide a private room near the nurse's station
Correct Answer: B
Rationale: Activities fostering self-identity address the underlying issues of low self-esteem and perfectionism common in anorexia nervosa.
The best size cathlon for administration of a blood transfusion to a six year old is:
- A. 18 gauge
- B. 19 gauge
- C. 22 gauge
- D. 20 gauge
Correct Answer: D
Rationale: A 20-gauge catheter is appropriate for blood transfusion in a six-year-old, balancing flow rate and vessel size.
The nurse is serving on the performance improvement committee, which has agreed to some changes in procedures on the basis of evidence-based research. If the committee wants to convince staff members to comply with the changes, which of the following actions should the committee carry out first?
- A. Identify and gain support of key staff.
- B. Explain the consequences of failure to comply.
- C. Determine a reward system for compliance.
- D. Clearly outline expectations in written format.
Correct Answer: A
Rationale: Gaining key staff support (A) builds buy-in and facilitates change adoption. Consequences (B), rewards (C), or written expectations (D) follow.
A 10-year-old girl has been diagnosed with scabies. There are three other children and two adults living in the household. The nurse can best educate caregivers by stating,
- A. Scabies is only transmitted through person-to-person contact.'
- B. Everyone in the household needs to receive treatment.'
- C. If anyone shows symptoms, come into the clinic for treatment.'
- D. Since the child has started treatment, she is no longer contagious.'
Correct Answer: B
Rationale: Scabies is highly contagious via skin-to-skin contact or shared items. All household members should be treated simultaneously to prevent reinfestation, regardless of symptoms.
The nurse working in an outpatient pain clinic has the opportunity to teach a client with chronic back pain about nonpharmacological pain management. Which of the following would be most appropriate for the nurse to include when teaching? Select all that apply.
- A. music
- B. therapeutic massage
- C. stretching exercises
- D. relaxation
Correct Answer: A, B, C, D
Rationale: Music, therapeutic massage, stretching exercises, and relaxation are all evidence-based nonpharmacological methods to manage chronic pain.