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A nurse in a provider's office is caring for a client who states, "I always have trouble sleeping." Which of the following actions should the nurse take first?
- A. Teach the client stress reduction techniques
- B. Recommend that the client avoid caffeine intake in the evening
- C. Identify the client's typical bedtime routine
- D. Encourage the client to exercise regularly during daytime hours
Correct Answer: C
Rationale: The correct action for the nurse to take first is to identify the client's typical bedtime routine. Understanding the client's sleep habits, environment, and bedtime rituals can provide valuable insight into potential factors contributing to their sleep troubles. Teaching stress reduction techniques (choice A) may be beneficial but should come after understanding the client's routine. Recommending avoiding caffeine intake in the evening (choice B) and encouraging regular daytime exercise (choice D) are important interventions, but identifying the bedtime routine takes precedence as it directly addresses the client's immediate concern.
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A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?
- A. Discontinue the machine and measure the blood pressure manually every 15 minutes.
- B. Adjust the machine settings.
- C. Clean the machine to ensure accuracy.
- D. Increase the frequency of the readings.
Correct Answer: B
Rationale: In this scenario, the nurse should adjust the machine settings. If the electronic blood pressure machine is providing varied intervals and inconsistent readings, it indicates a potential malfunction. Changing the settings may help correct the issue and ensure accurate measurements. Discontinuing the machine and measuring manually every 15 minutes (Choice A) may be time-consuming and impractical. Cleaning the machine (Choice C) is important for routine maintenance but may not address the current issue of varied intervals and inconsistent readings. Increasing the frequency of the readings (Choice D) does not address the problem of inaccurate measurements caused by the malfunctioning machine.
A client is drawing up and mixing insulin under the observation of a nurse. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?
- A. The client is able to discuss the appropriate technique.
- B. The client is able to demonstrate the appropriate technique.
- C. The client states an understanding of the process.
- D. The client is able to write the steps on a piece of paper.
Correct Answer: B
Rationale: The correct answer is B because the ability to demonstrate the appropriate technique shows that the client has acquired the psychomotor skills needed for insulin preparation. Merely discussing, stating an understanding, or writing the steps does not confirm that the client can physically perform the task correctly. Being able to demonstrate indicates practical application and mastery of the skill. Choice A is incorrect because discussing the technique does not necessarily mean the client can physically perform it. Choice C is incorrect as stating an understanding does not guarantee the client's ability to perform the task. Choice D is incorrect because writing the steps does not assess the client's physical execution of the technique.
In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will:
- A. Be at an increased susceptibility for infection
- B. Have a wound that heals more slowly
- C. Experience more pain during the healing process
- D. Require more frequent dressing changes
Correct Answer: A
Rationale: Wounds healing by secondary intention involve the gradual filling of the wound with granulation tissue, leading to a higher risk of infection due to prolonged exposure. This makes choice A the correct answer. Choices B and C are incorrect because wounds healing by secondary intention take longer to heal and often result in more pain compared to wounds healing by primary intention. Choice D is also incorrect as wounds healing by secondary intention usually require more frequent dressing changes to prevent infection and promote healing.
A client is receiving morphine via PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?
- A. I'll wait to use the device until it's absolutely necessary.
- B. I'll be careful about pushing the button too much to avoid an overdose.
- C. I should tell the nurse if the pain doesn't stop while I am using this device.
- D. I will ask my adult child to push the dose button when I am sleeping.
Correct Answer: C
Rationale: Choice C is the correct answer because it demonstrates that the client understands the importance of communicating with the nurse if the pain persists while using the PCA device. This is crucial as it ensures proper pain management and monitoring. Choices A and B are incorrect because delaying the use of the device until necessary or being cautious about pushing the button too much do not necessarily reflect understanding of using the PCA device effectively. Choice D is incorrect as having someone else, like an adult child, push the dose button goes against the principle of the client self-administering the medication through the PCA device.
A nurse in a surgical suite notes documentation on a client's medical record stating that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?
- A. Ensure sterilization of non-disposable items with ethylene oxide
- B. Wrap monitoring cords with stockinette and secure them with non-latex tape
- C. Cleanse latex ports on IV tubing with chlorhexidine before administering medication
- D. Wear hypoallergenic latex gloves that are powder-free
Correct Answer: B
Rationale: In this scenario, the nurse should take precautions to prevent latex exposure to the client due to his latex allergy. Wrapping monitoring cords with stockinette and securing them with non-latex tape helps to minimize the risk of latex contact with the client. Choice A is incorrect as sterilizing non-disposable items with ethylene oxide does not specifically address the avoidance of latex exposure. Choice C involves using latex ports on IV tubing, which can pose a risk of allergic reaction in a client with a latex allergy. Choice D suggests wearing latex gloves, even if hypoallergenic, which can still trigger a reaction in individuals with latex allergy. Therefore, the best option is to choose non-latex materials like stockinette and non-latex tape to prevent direct contact with latex.