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A female client with deteriorating neurologic function states, "I am worried I will not be able to care for my young children."? How does the nurse respond?
- A. "Caring for your children is a priority. You may not want to ask for help, but you have to."?
- B. "Our community has resources that may help you with some household tasks so you have energy to care for your children."?
- C. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?"?
- D. "Give me more information about what worries you, so we can see if we can do something to make adjustments."?
Correct Answer: D
Rationale: When a client expresses worry about not being able to care for her children due to deteriorating neurologic function, the most appropriate response from the nurse is to gather more information from the client. This open-ended approach allows the nurse to better understand the client's specific concerns and needs, leading to tailored interventions and support. Choice A is dismissive and may make the client feel guilty for needing help. Choice B focuses on external resources without addressing the client's worries directly. Choice C suggests a psychological referral without exploring the client's concerns further. Therefore, the correct response is to gather more information to provide personalized support.
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The nurse teaches a client who is newly diagnosed with coronary artery disease. Which instruction does the nurse include to minimize complications of this disease?
- A. "Rest is the best medicine at this time. Do not start an exercise program."?
- B. "You are a man; therefore, there is nothing you can do to minimize your risks."?
- C. "You should talk to your provider about medications to help you quit smoking."?
- D. "Decreasing the carbohydrates in your diet will help you lose weight."?
Correct Answer: C
Rationale: The correct answer is to advise the client to talk to their provider about medications to help quit smoking. Smoking is a major risk factor for coronary artery disease, and quitting smoking can significantly reduce the risk of complications. Choice A is incorrect because exercise is beneficial for managing coronary artery disease, but should be started gradually and under guidance. Choice B is incorrect and inappropriate as it undermines the client's ability to take control of their health. Choice D is incorrect because while a balanced diet is important, specifically targeting carbohydrates alone may not be the most effective or healthy approach for managing coronary artery disease.
The nurse is caring for a client who has had surgery the previous day. The client tells the nurse, "Breathing in using this thing (incentive spirometer) is a ridiculous waste of time."? What is the nurse's best response?
- A. "The spirometer will help you cough effectively."?
- B. "The spirometer will help your lungs expand."?
- C. "The spirometer will help prevent blood clots."?
- D. "The spirometer will improve blood flow in your lungs."?
Correct Answer: B
Rationale: The correct answer is, '"The spirometer will help your lungs expand."?' Incentive spirometry is used postoperatively to help prevent atelectasis by expanding the lungs and improving lung function. Choice A is incorrect because the primary purpose of the spirometer is not to help cough effectively. Choice C is incorrect because while deep breathing with the spirometer can indirectly help prevent blood clots by improving lung function, its primary purpose is not to prevent blood clots directly. Choice D is incorrect because although using the spirometer can improve ventilation and oxygenation, its main purpose is not to improve blood flow in the lungs.
A client is receiving an IV infusion of an antibiotic. The client calls the nurse feeling uneasy due to congestion. Which action by the nurse is most appropriate?
- A. Elevate the head of the client's bed to 45 degrees
- B. Have another nurse call the Rapid Response Team
- C. Prepare to administer diphenhydramine (Benadryl)
- D. Slow the rate of the IV infusion
Correct Answer: B
Rationale: In this situation, the client's symptoms of congestion and feeling uneasy may indicate an anaphylactic reaction, which can be life-threatening. The most appropriate action is to call the Rapid Response Team to provide immediate assistance and interventions. Elevating the head of the bed, administering diphenhydramine, or slowing the IV infusion rate are not the priority actions in the case of a potential severe allergic reaction. These interventions may delay necessary emergency care and potentially worsen the client's condition.
The healthcare provider is assessing a client before surgery. Which assessments contraindicate the client from having surgery as scheduled? (Select one that does not apply.)
- A. Potassium level of 2.8 mEq/L
- B. International normalized ratio (INR) of 4
- C. Prothrombin time (PT) of 30 seconds
- D. Positive pregnancy test
Correct Answer: C
Rationale: The correct answer is C: Prothrombin time (PT) of 30 seconds. A low potassium level (choice A) and an elevated INR (choice B) indicate potential bleeding risks during surgery. A positive pregnancy test (choice D) in a female client can lead to complications during surgery. However, a Prothrombin time of 30 seconds is within the normal range and does not contraindicate the client from having surgery as scheduled.
When the client finds antiembolism stockings uncomfortably tight, what is the nurse's best action?
- A. Remove the stockings for an hour to relieve the pressure
- B. Pull the stockings down so that they are not constricting
- C. Measure the client's calf to ensure that they are the correct size
- D. Teach the client the purpose of wearing the stockings
Correct Answer: D
Rationale: The correct action for the nurse to take when a client finds antiembolism stockings uncomfortably tight is to teach the client the purpose of wearing the stockings. This educates the client on the importance of the stockings in preventing blood clots and encourages compliance. Removing the stockings or pulling them down may compromise their effectiveness. Measuring the client's calf size is not necessary in this situation as the discomfort is due to tightness, not incorrect sizing.