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A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching?
- A. Apply petroleum jelly to soothe the mucous membranes.
- B. Use synthetic fabrics for the client's bedding.
- C. Clean the equipment with an alcohol-based cleaning product.
- D. Avoid using nail polish remover around the client.
Correct Answer: D
Rationale: The correct answer is D: Avoid using nail polish remover around the client. Nail polish remover contains acetone, which is highly flammable and can pose a serious risk when in contact with oxygen therapy equipment. It is crucial to prevent any potential sources of ignition near oxygen therapy to ensure the safety of the client.
Incorrect choices:
A: Apply petroleum jelly to soothe the mucous membranes - Petroleum jelly is flammable and should not be used near oxygen therapy.
B: Use synthetic fabrics for the client's bedding - The type of bedding material is not directly related to home oxygen therapy.
C: Clean the equipment with an alcohol-based cleaning product - Alcohol-based products are flammable and should be avoided around oxygen therapy equipment.
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A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?
- A. Soak feet twice daily.
- B. Round the edges of toenails when trimming.
- C. Use moisturizing lotion between the toes.
- D. Wear clean cotton socks every day.
Correct Answer: D
Rationale: The correct answer is D: Wear clean cotton socks every day. This instruction is essential for proper foot care in diabetes mellitus as it helps prevent fungal infections and keeps feet dry. Soaking feet twice daily (choice A) can lead to skin breakdown. Rounding the edges of toenails (choice B) can increase the risk of ingrown toenails. Using moisturizing lotion between the toes (choice C) can create a moist environment, fostering fungal growth. Therefore, wearing clean cotton socks daily is the most appropriate instruction to promote foot health in a client with diabetes mellitus.
A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.)
- A. Lacrimal apparatus
- B. Pupil clarity
- C. Appearance of bulbar conjunctivae
- D. Visual fields
- E. Visual acuity
Correct Answer: B,C,D,E
Rationale: The correct assessments for identifying an older adult client's safety needs are B, C, D, and E. Pupil clarity is crucial for detecting any visual impairments that may increase fall risk. The appearance of bulbar conjunctivae can indicate underlying eye conditions affecting vision and balance. Assessing visual fields helps identify potential blind spots that may contribute to falls. Visual acuity is essential for clear vision and spatial awareness, both critical for preventing falls. Choices A and F have no direct relevance to assessing fall risk in older adults, making them incorrect options.
A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan?
- A. Wear loose-fitting underwear.
- B. Take a bubble bath after intercourse.
- C. Drink four 240 mL (8 oz) glasses of water each day.
- D. Void every 5 to 6 hr during the day.
Correct Answer: A
Rationale: Correct Answer: A: Wear loose-fitting underwear.
Rationale:
1. Loose-fitting underwear allows for better air circulation, reducing moisture and bacterial growth.
2. Tight clothing can create a warm, moist environment ideal for bacterial growth.
3. Preventing moisture buildup can help reduce the risk of urinary tract infections.
Summary of other choices:
B: Taking a bubble bath after intercourse can introduce bacteria into the urinary tract, increasing the risk of infection.
C: Drinking water is important for overall health but does not directly prevent urinary tract infections.
D: Voiding every 5 to 6 hours is a good practice, but it does not directly address the prevention of urinary tract infections.
A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who is ambulatory and receiving oxygen
- B. A client who has a fracture and is in balance suspension traction
- C. A client who is bedridden and wears a hearing aid
- D. A client who uses a wheelchair and is confused
Correct Answer: A
Rationale: The correct answer is A: A client who is ambulatory and receiving oxygen should be evacuated first during a fire. This client has the highest risk due to the combination of mobility impairment and oxygen use, which increases the potential for rapid deterioration in a fire emergency. Oxygen supports combustion, making this client more vulnerable to fire-related injuries.
Choice B: A client with a fracture in balance suspension traction is stable and can wait for evacuation. Choice C: A bedridden client with a hearing aid can still hear evacuation instructions and wait for assistance. Choice D: A confused client in a wheelchair may require assistance but is not at immediate risk like the ambulatory client with oxygen.
A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the nurse plan to use during the group session?
- A. Encourage clients to establish a timeline for their own grieving process.
- B. Initiate a discussion with clients about ways to cope with changes in family dynamics.
- C. Assist clients in identifying ways suicide could have been prevented.
- D. Discourage clients from sharing negative aspects of their relationship with the deceased persons.
Correct Answer: B
Rationale: The correct answer is B: Initiate a discussion with clients about ways to cope with changes in family dynamics. This strategy is important in supporting clients dealing with the aftermath of a family member's suicide as it acknowledges the significant impact on family dynamics. It allows clients to explore and process the changes within the family system and develop coping mechanisms. This approach fosters open communication and mutual support within the group.
Choice A is incorrect because grief is a highly individualized process and establishing a timeline may not be helpful or realistic for everyone. Choice C is incorrect as it may inadvertently place blame on the deceased and lead to feelings of guilt among clients. Choice D is incorrect as it can hinder the healing process by suppressing valid emotions and preventing the group from exploring their feelings openly.