Nokea
A male client who had abdominal surgery has a nasogastric tube for suction, oxygen via nasal cannula, and complains of dry mouth. Which action should the nurse implement?
- A. Apply a petroleum-based lubricant to the lips.
- B. Give sips of water.
- C. Provide ice chips.
- D. Apply a water-soluble lubricant to the lips, oral mucosa, and nares.
Correct Answer: D
Rationale: In this scenario, the correct action is to apply a water-soluble lubricant to the lips, oral mucosa, and nares. This helps in keeping the mucous membranes moist, which is essential for a client with a dry mouth due to the nasogastric tube and oxygen therapy. Choice A, applying a petroleum-based lubricant to the lips, is not suitable as it may not be safe for internal use. Choice B, giving sips of water, is contraindicated as the client has a nasogastric tube in place for suction. Choice C, providing ice chips, is also not recommended as the client needs proper lubrication to address dryness, not cold stimulation.
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In conducting a health assessment for a family with a history of cardiovascular disease, which family member should be prioritized for further evaluation and intervention?
- A. a 45-year-old father who smokes and has high cholesterol
- B. a 17-year-old daughter who is overweight and inactive
- C. a 50-year-old mother with a history of hypertension
- D. a 12-year-old son who has a normal weight and is active
Correct Answer: A
Rationale: The 45-year-old father who smokes and has high cholesterol is at a higher risk for cardiovascular disease due to multiple risk factors. Smoking and high cholesterol are significant contributors to the development of cardiovascular issues. Prioritizing his evaluation and intervention is crucial to address these modifiable risk factors. The other family members, though they may have risk factors as well, do not present with the same level of immediate risk based on the information provided.
The healthcare provider is caring for a client with hypokalemia. Which assessment finding requires immediate intervention?
- A. Muscle weakness.
- B. Irregular heart rate.
- C. Increased urinary output.
- D. Decreased deep tendon reflexes.
Correct Answer: D
Rationale: Decreased deep tendon reflexes are a critical finding in hypokalemia that indicates severe potassium deficiency affecting neuromuscular function. Immediate intervention is necessary to prevent life-threatening complications such as respiratory failure or cardiac arrhythmias. Muscle weakness, irregular heart rate, and increased urinary output are also associated with hypokalemia but do not pose the same level of urgency as decreased deep tendon reflexes.
The nurse identifies a client's needs and formulates the nursing problem of 'Imbalance nutrition: Less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months.' Which short-term goal is best for this client?
- A. Eat 50% of six small meals each day by the end of the week.
- B. Gain 5 pounds by the end of the month.
- C. Have increased caloric intake.
- D. Show improved nutritional status.
Correct Answer: A
Rationale: The correct short-term goal for the client in this scenario is option A: 'Eat 50% of six small meals each day by the end of the week.' This goal is specific, measurable, and time-bound, which aligns with the SMART criteria for goal setting in nursing care. It addresses the client's nutritional needs directly, focusing on increasing meal frequency to meet body requirements and counteract weight loss. Option B, 'Gain 5 pounds by the end of the month,' is not as suitable as it lacks specificity and a short-term timeline, making it less achievable within the immediate care plan. Option C, 'Have increased caloric intake,' is vague and does not provide a measurable target for the client to work towards. Option D, 'Show improved nutritional status,' is a broad goal that lacks the specificity needed for effective short-term goal setting in nursing care. Therefore, option A is the most appropriate choice for this client's short-term goal.
The healthcare professional is developing a health education program for adolescents on the dangers of smoking. Which strategy is most likely to be effective?
- A. showing graphic images of the effects of smoking
- B. inviting former smokers to share their experiences
- C. providing statistical data on smoking-related illnesses
- D. distributing pamphlets on smoking cessation resources
Correct Answer: B
Rationale: Inviting former smokers to share their experiences is the most effective strategy because personal stories can have a powerful impact on adolescents and motivate them to avoid smoking. This approach makes the consequences of smoking more relatable and real, potentially influencing behavior change. Showing graphic images may be too harsh and could lead to desensitization or avoidance of the issue. Providing statistical data may not resonate as strongly with adolescents as personal stories. Distributing pamphlets, while informative, may not have the same emotional impact as hearing real-life experiences.
A public health nurse is working with a community to improve access to healthcare services. Which intervention is most likely to be effective?
- A. Setting up mobile clinics in underserved areas
- B. Distributing flyers with information about local clinics
- C. Offering transportation vouchers for medical appointments
- D. Partnering with local businesses to provide healthcare discounts
Correct Answer: A
Rationale: Setting up mobile clinics in underserved areas is the most effective intervention to improve access to healthcare services. Mobile clinics directly bring healthcare services to the community, making it convenient for residents to access care without having to travel long distances. Distributing flyers may increase awareness but may not address the barriers to access. Offering transportation vouchers helps with one aspect of access but does not directly provide healthcare services. Partnering with local businesses for discounts may not address the primary issue of physical access to healthcare services in underserved areas.