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A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?
- A. Ask him to rate his pain on a scale of 1 to 10.
- B. Encourage him to wait until bedtime so the pill can help him sleep.
- C. Attend to an acutely ill client's needs first because this client is laughing.
- D. Instruct him in the use of deep breathing exercises for pain control.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?
- A. Autopsy of the body is prohibited.
- B. Blood transfusions are forbidden.
- C. Alcohol use in any form is not allowed.
- D. A vegetarian diet must be followed.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client is being instructed on the proper use of a metered-dose inhaler. Which instruction should be provided to ensure the optimal benefits from the drug?
- A. Fill your lungs with air through your mouth and then compress the inhaler.
- B. Compress the inhaler while slowly breathing in through your mouth.
- C. Compress the inhaler while inhaling quickly through your nose.
- D. Exhale completely after compressing the inhaler and then inhale.
Correct Answer: B
Rationale: The correct technique for using a metered-dose inhaler involves compressing the inhaler while slowly breathing in through the mouth. This method helps ensure that the medication reaches deep into the lungs, allowing for optimal bronchodilation effect. Inhaling quickly through the nose or filling the lungs with air before compressing the inhaler are not recommended techniques for using a metered-dose inhaler effectively.
While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
- A. Suction deeper to remove secretions.
- B. Gently withdraw suction tubing to allow suction or coughing out of mucus.
- C. Remove the suction as quickly as possible.
- D. Insert and remove the suction multiple times to clear secretions.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?
- A. Obtain a prescription from the healthcare provider regarding visitation privileges
- B. Request a consultation with the ethics committee for resolution of the situation
- C. Encourage the client to speak with her husband regarding his disruptive behavior
- D. Communicate the client's wishes to all members of the multidisciplinary team
Correct Answer: B
Rationale: In a situation where a client's estranged husband demands to restrict the visitation of the significant other, it is essential to prioritize the client's wishes while addressing the conflict. Requesting a consultation with the ethics committee is appropriate as it allows for a comprehensive and impartial resolution, ensuring the client's autonomy and well-being are upheld.
During a client assessment, the healthcare provider is evaluating cranial nerve function. Which assessment finding suggests that cranial nerve II is intact?
- A. The client can hear a whisper from 1 to 2 feet away.
- B. The client can identify an object by touch.
- C. The client can shrug the shoulders against resistance.
- D. The client can read a Snellen chart from 20 feet away.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.