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A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?
- A. Proceed to measure the oral temperature.
- B. Document that the nurse was unable to measure the client's temperature.
- C. Provide the client a sip of warm water, wait 5 min, and measure the temperature.
- D. Wait 30 min and return to measure the oral temperature.
Correct Answer: D
Rationale: The correct answer is D: Wait 30 min and return to measure the oral temperature. When a client eats ice chips, the oral temperature may be falsely low due to the cold temperature of the ice. Waiting 30 minutes allows the oral cavity to return to its normal temperature, ensuring an accurate reading. Option A is incorrect because immediate measurement would yield an inaccurate result. Option B is incorrect as it does not address the issue of the ice chips affecting the temperature reading. Option C is incorrect as providing warm water may not be sufficient to normalize the temperature.
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A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?
- A. Urine is cloudy after sitting in the urinal for 6 hours.
- B. First-voided urine in the morning has a strong odor.
- C. Urine output of 175 mL in the past 8 hours.
- D. Urine output of 2,200 mL in the past 24 hours.
Correct Answer: C
Rationale: The correct answer is C. The nurse should notify the provider about a urine output of 175 mL in the past 8 hours for a client with impaired renal function as it indicates decreased urine output, which can be a sign of worsening renal function. This finding may suggest renal failure or dehydration, requiring immediate intervention. Choice A is incorrect as cloudy urine after sitting is not unusual and may result from urinary sediment. Choice B is incorrect as a strong odor in the first-voided urine is common and not necessarily concerning. Choice D is incorrect as a urine output of 2,200 mL in 24 hours is within the normal range.
A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?
- A. Obtain the client's consent.
- B. Explain the procedure to the client if they do not understand.
- C. Witness the client's signature.
- D. Explain the risks and benefits of the procedure.
Correct Answer: C
Rationale: The correct answer is C: Witness the client's signature. This is crucial to ensure that the client is voluntarily giving consent for the surgical procedure. By witnessing the signature, the nurse confirms that the client is fully informed and agrees to the procedure. Obtaining consent (Choice A) is important but witnessing the client's signature (Choice C) validates that the consent is authentic. Explaining the procedure (Choice B) and risks and benefits (Choice D) are essential parts of the informed consent process but witnessing the signature is the final step to confirm the client's agreement.
A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take?
- A. Use attentive listening with the client.
- B. Focus on the client's present circumstances instead of his personal stories.
- C. Offer the client personal thoughts and beliefs.
- D. Verbalize understanding of how the client feels.
Correct Answer: A
Rationale: The correct answer is A: Use attentive listening with the client. Attentive listening is a key aspect of the communication principle of presence as it shows the client that the nurse is fully engaged, focused, and empathetic. By actively listening, the nurse can understand the client's needs and perspectives, which is essential for building a collaborative relationship. It allows the nurse to demonstrate respect, empathy, and validation towards the client's feelings and experiences.
Choice B is incorrect because focusing on the client's present circumstances only and ignoring personal stories may hinder the establishment of a deeper connection and understanding. Choice C is incorrect as offering personal thoughts and beliefs can shift the focus away from the client and may lead to biases or misunderstandings. Choice D is incorrect because verbalizing understanding of how the client feels is important, but it is not the primary action associated with the communication principle of presence.
A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?
- A. Check residual volume every 4 to 6 hr.
- B. Observe client's respiratory status.
- C. Elevate the head of the client's bed 30° to 45°.
- D. Monitor intake and output every 8 hr.
Correct Answer: C
Rationale: The correct answer is C: Elevate the head of the client's bed 30° to 45°. This is the priority action because it helps prevent aspiration in a client with decreased consciousness receiving enteral feedings. By elevating the head of the bed, gravity helps keep the feeding in the stomach and reduces the risk of reflux into the lungs, which can lead to aspiration pneumonia.
Checking residual volume (choice A) is important but not the priority. Observing respiratory status (choice B) is also crucial but secondary to preventing aspiration. Monitoring intake and output (choice D) is a routine nursing task but not as critical as preventing aspiration. The key is to prioritize actions that directly impact the client's safety and well-being, which in this case is elevating the head of the bed.
A nurse is instructing a group of clients regarding nutrition. Which of the following is a good source of omega-3 fatty acids that the nurse should include in the teaching?
- A. Fish
- B. Leafy green vegetables
- C. Dietary supplements
- D. Corn oil
Correct Answer: A
Rationale: The correct answer is A: Fish. Fish, especially fatty fish like salmon and mackerel, are excellent sources of omega-3 fatty acids such as EPA and DHA, which have numerous health benefits including reducing inflammation and supporting heart health. Leafy green vegetables (B) typically do not contain significant amounts of omega-3s. Dietary supplements (C) can be a source of omega-3s, but whole foods like fish are preferred for better absorption and overall nutrition. Corn oil (D) is not a good source of omega-3s and is higher in omega-6 fatty acids.