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A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care?
- A. Amount of support provided by family members
- B. Measurement of pain using a scale of 0 to 10
- C. The ability to perform ADLs
- D. Nonverbal behaviors exhibited when pain occurs
Correct Answer: C
Rationale: Assessing the client's ability to perform activities of daily living (ADLs) is crucial in planning care for someone with chronic pain. Understanding the client's functional status helps the nurse tailor interventions to promote independence and enhance quality of life. It provides valuable insight into the impact of pain on daily activities and guides the development of a comprehensive care plan to address the client's specific needs.
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In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible?
- A. Daily black, sticky stool
- B. Daily dark brown stool
- C. Firm brown stool every other day
- D. Soft light brown stool twice a day
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
- A. Americans with Disabilities Act of 1990
- B. ANA Code of Ethics with Interpretative Statements
- C. ANA's Scope and Standards of Nursing Practice
- D. Patient's Bill of Rights of 1990
Correct Answer: C
Rationale: The ANA's Scope and Standards of Nursing Practice are essential guidelines for nursing practice in various specialties, including mental health. The document outlines the expectations and responsibilities of nurses in providing high-quality care within their specific practice areas. In the context of opening a mental health services department, using the Scope and Standards specific to psychiatric-mental health nursing would ensure that the unit's nursing guidelines align with best practices and professional standards in mental health care.
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.
A client is to receive cimetidine (Tagamet) 300 mg q6h IVP. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?
- A. 75 ml/hr
- B. 150 ml/hr
- C. 225 ml/hr
- D. 300 ml/hr
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When is the first dose of Hepatitis B given?
- A. In the hospital at birth
- B. At one year old
- C. At six months
- D. At 18 months
Correct Answer: A
Rationale: The first dose of the Hepatitis B vaccine is usually administered at birth in the hospital to provide early protection against the virus. Giving the vaccine at birth helps prevent perinatal transmission of Hepatitis B from an infected mother to her newborn. Therefore, it is important to administer the first dose as soon as possible after birth to ensure the best protection.