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A healthcare professional is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the healthcare professional use as a psychomotor approach to learning?
- A. Practice sessions
- B. Demonstrations
- C. Written instructions
- D. Group discussions
Correct Answer: A
Rationale: Practice sessions are an effective psychomotor approach to learning for adolescents with ostomies as they involve hands-on practice of ostomy care skills, which can help reinforce learning through active engagement. Demonstrations (choice B) can be helpful in providing visual guidance but may not offer the same level of active participation and practice as practice sessions. Written instructions (choice C) may be useful for reference but may not be as effective in developing psychomotor skills. Group discussions (choice D) focus more on verbal exchange and may not directly address the need for hands-on skill development required in managing ostomies. Therefore, practice sessions are the most suitable method for enhancing psychomotor learning in this scenario.
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A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
- A. 2 cups of soup
- B. 1 quart of water
- C. 8 oz of ice chips
- D. 6 oz of tea
Correct Answer: C
Rationale: The correct answer is C: 8 oz of ice chips. When calculating fluid intake, the nurse should document half of the volume of ice chips to account for the air in between the chips. Therefore, 8 oz of ice chips equals 120 mL of fluid. Choices A, B, and D are incorrect because they do not equate to 120 mL of fluid intake as per the given scenario. Choice A, 2 cups of soup, is more than 120 mL. Choice B, 1 quart of water, is significantly more than 120 mL. Choice D, 6 oz of tea, is less than 120 mL.
A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the nurse to take?
- A. Administer oxygen via a nasal cannula.
- B. Measure the client's vital signs.
- C. Obtain a 12-lead ECG.
- D. Encourage the client to use pursed-lip breathing.
Correct Answer: A
Rationale: Administering oxygen via a nasal cannula is the priority action for a client experiencing chest pain due to coronary artery disease. Oxygen therapy helps improve oxygenation, reduce myocardial workload, and relieve chest pain by increasing oxygen delivery to the heart muscle. While measuring vital signs, obtaining a 12-lead ECG, and encouraging pursed-lip breathing are important interventions, administering oxygen takes precedence in this situation to address the potential hypoxemia associated with chest pain in a client with a history of coronary artery disease.
When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?
- A. Place the client in a side-lying position
- B. Instill 15 mL of irrigation fluid into the catheter with each flush
- C. Subtract the amount of irrigant used from the client's urine output
- D. Perform the irrigation using a 20 mL syringe
Correct Answer: C
Rationale: The correct action for the nurse to take when using an open irrigation technique on a client with an indwelling urinary catheter is to subtract the amount of irrigant used from the client's urine output. This calculation helps ensure an accurate measurement of the client's actual urine output by accounting for the irrigation fluid introduced into the catheter. Placing the client in a side-lying position (Choice A) is not directly related to the irrigation procedure. Instilling a specific volume of irrigation fluid (Choice B) may vary depending on the client's condition and the healthcare provider's order. Using a 20 mL syringe for irrigation (Choice D) is a matter of equipment choice and does not directly impact the calculation of urine output in this context.
A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?
- A. Bend at the knees while maintaining a wide stance and a straight back, with the client's hands on the nurse's shoulders, and the nurse's hands under the client's axillae
- B. Use a mechanical lift
- C. Twist at the waist while holding the client
- D. Ask for assistance from another staff member
Correct Answer: A
Rationale: The correct technique for transferring a client from a bed to a chair to avoid back injuries is to bend at the knees while maintaining a wide stance and a straight back. This position ensures that the nurse uses leg muscles rather than the back muscles for lifting, reducing the risk of injury. Placing the client's hands on the nurse's shoulders and the nurse's hands under the client's axillae provides additional support and stability during the transfer. Using a mechanical lift may be appropriate for certain situations but is not necessary for a simple bed-to-chair transfer. Twisting at the waist while holding the client can lead to back strain or injury. Asking for assistance from another staff member is a good practice, but proper body mechanics should still be followed to ensure safe client handling.
A client is drawing up and mixing insulin under the observation of a nurse. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?
- A. The client is able to discuss the appropriate technique.
- B. The client is able to demonstrate the appropriate technique.
- C. The client states an understanding of the process.
- D. The client is able to write the steps on a piece of paper.
Correct Answer: B
Rationale: The correct answer is B because the ability to demonstrate the appropriate technique shows that the client has acquired the psychomotor skills needed for insulin preparation. Merely discussing, stating an understanding, or writing the steps does not confirm that the client can physically perform the task correctly. Being able to demonstrate indicates practical application and mastery of the skill. Choice A is incorrect because discussing the technique does not necessarily mean the client can physically perform it. Choice C is incorrect as stating an understanding does not guarantee the client's ability to perform the task. Choice D is incorrect because writing the steps does not assess the client's physical execution of the technique.