Nokea
A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?
- A. "It must be difficult to care for someone who is confined to bed."
- B. "It is important to keep the client clean to avoid infections."
- C. "I understand that this is challenging; let's work together to ensure comfort."
- D. "The smell is quite strong; we need to address this immediately."
Correct Answer: C
Rationale: The correct response is C: "I understand that this is challenging; let's work together to ensure comfort." This response acknowledges the difficulty the partner is facing, shows empathy, and offers to collaborate in providing care. Choice A is incorrect because it does not directly address the partner's feelings of embarrassment or offer support. Choice B, while true, does not address the partner's emotional state and may come across as directive rather than supportive. Choice D is also incorrect as it focuses solely on the smell without addressing the partner's emotions or offering assistance in managing the situation with empathy.
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Twenty minutes after starting a heat application, the client mentions that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN?
- A. That indicates you have derived the maximum benefit, and the heat can be removed.
- B. Your blood vessels are dilating and removing the heat from the site.
- C. We will increase the temperature by 5 degrees when the pad no longer feels warm.
- D. The body's receptors adapt over time as they are exposed to heat.
Correct Answer: D
Rationale: Choice D is the correct response. The body's receptors adapt to the heat over time, which can explain why the client no longer perceives the warmth from the heating pad. This phenomenon is known as thermal adaptation. Choices A, B, and C are incorrect. Choice A is inaccurate because the client not feeling the warmth does not necessarily mean they have derived the maximum benefit. Choice B incorrectly states that blood vessels dilating remove heat, which is not accurate. Choice C suggests increasing the temperature when the pad no longer feels warm, which could potentially lead to burns or discomfort for the client.
A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight, and that the client is now lying unconscious on the floor. What is the most important action the LPN/LVN needs to take?
- A. Ask the client if he is okay.
- B. Call security from the room.
- C. Find out if there is anyone else in the room.
- D. Ask security to make sure the room is safe.
Correct Answer: D
Rationale: The most critical action for the LPN/LVN to take in this situation is to ask security to ensure the room is safe. This step is crucial to prevent any further harm to the unconscious client or others. While it is important to assess the client's condition, ensuring safety takes precedence. Calling security from the room may expose the LPN/LVN to potential danger without confirming the safety of the environment first. Finding out if anyone else is in the room can wait until safety is established to avoid unnecessary risks.
The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind?
- A. Patients who appear unkempt may require guidance on hygiene practices.
- B. Personal preferences can be influenced by health conditions.
- C. The patient's illness may require teaching of new hygiene practices.
- D. Cultural perspectives on cleanliness can vary based on health status.
Correct Answer: C
Rationale: In this scenario, the patient's diagnosis of diabetes may necessitate adjustments to their hygiene practices. The nurse should recognize that certain illnesses, like diabetes, can impact hygiene needs. Choice A is incorrect because appearing unkempt does not necessarily indicate a lack of importance on hygiene practices; it may be due to various factors. Choice B is incorrect as health conditions can influence personal preferences and habits. Choice D is incorrect as cultural views on cleanliness are not the primary focus when addressing hygiene practices related to a specific illness.
A nurse is planning strategies to manage time effectively for client care. What should the nurse implement?
- A. Use the planning step of the nursing process to prioritize client care delivery.
- B. Delegate all tasks to assistive personnel.
- C. Focus on completing tasks in the order they are assigned.
- D. Avoid using a checklist for daily tasks.
Correct Answer: A
Rationale: The correct answer is A. Using the planning step of the nursing process to prioritize client care delivery is crucial for effective time management. By prioritizing tasks based on client needs and acuity levels, the nurse can ensure that the most critical care is provided in a timely manner. Choice B is incorrect because while delegation is important, not all tasks can be delegated, and the nurse is ultimately responsible for the care provided. Choice C is incorrect as completing tasks in the order they are assigned may not align with the urgency of client needs. Choice D is incorrect as using a checklist can help the nurse stay organized and ensure that all necessary tasks are completed.
A client with a chest tube following thoracic surgery needs care. Which task should the nurse delegate to an assistive personnel?
- A. Teach deep breathing and coughing to the client.
- B. Assist the client to select food choices from the menu.
- C. Evaluate the client's response to pain medication.
- D. Monitor the characteristics of the client's chest tube drainage.
Correct Answer: B
Rationale: The correct answer is B because assisting the client with food choices is a task that can be safely delegated to assistive personnel. This task does not require nursing judgment or specialized skills. Choices A, C, and D involve assessing the client's condition, response to treatment, and monitoring critical aspects of care, which are nursing responsibilities that necessitate specialized knowledge and judgment. Teaching deep breathing and coughing (A), evaluating pain medication response (C), and monitoring chest tube drainage (D) require a higher level of training and expertise that should be performed by the nurse.