Nokea
A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?
- A. Dyspnea
- B. Pain at the surgical site
- C. Mild nausea
- D. Temperature of 37.5°C (99.5°F)
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Dyspnea in a postoperative client with a history of pulmonary embolism indicates a potential complication, such as a recurrent or new pulmonary embolism, which can be life-threatening. The nurse should report this finding to the provider immediately for further evaluation and intervention to prevent worsening respiratory distress and potential respiratory failure. Pain at the surgical site (choice B) is expected postoperatively and can be managed with appropriate pain medications. Mild nausea (choice C) is a common postoperative symptom and can be managed with antiemetic medications. A temperature of 37.5°C (99.5°F) (choice D) may indicate a mild fever, which can be monitored unless accompanied by other concerning symptoms.
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A nurse in a family health clinic is caring for a client who requests information regarding the correct use of condoms.
Which of the following statements should the nurse make?
- A. When using implanted contraceptive methods, condoms should also be used to protect against STDs.
- B. Use of petroleum-based lubricant with a condom increases the condom's effectiveness
- C. Ensure that the condom fits snugly over the tip of the penis
- D. Condoms are equally effective for birth control with or without the use of vaginal spermicides
Correct Answer: A
Rationale: The correct answer is A. This statement is correct because implanted contraceptive methods, like hormonal implants, do not protect against sexually transmitted diseases (STDs), so using condoms is necessary for dual protection. Choice B is incorrect as petroleum-based lubricants can weaken condoms. Choice C is incorrect because a condom should fit comfortably, not snugly, to prevent breakage. Choice D is incorrect because condoms are more effective for birth control when used with spermicide.
A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother.
Which of the following responses should the nurse make?
- A. I can give you information about respite care if you are interested.
- B. You should try to sleep more so you can take better care of your mother.
- C. Caring for a loved one at the end of life is very rewarding.
- D. It's important to stay strong for your mother during this time.
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the caregiver's potential interest in respite care, which can provide them with much-needed rest and support. This response shows empathy and offers a helpful solution. Choice B is incorrect as it oversimplifies the situation and places undue pressure on the caregiver. Choice C is incorrect as it may invalidate the caregiver's struggles and emotions, as caregiving can be overwhelming and challenging. Choice D is incorrect as it emphasizes the importance of strength without addressing the caregiver's need for support and self-care.
A nurse is conducting an initial assessment of a client and notices a discrepancy Between the clients current IV infusion and the information received during the shift's report.
Which of the following actions should the nurse take?
- A. Compare the current infusion with the prescription and the client's medical record.
- B. Adjust the IV infusion rate to match the information received during the shift report.
- C. Stop the infusion immediately and notify the provider.
- D. Document the discrepancy in the client's record and continue monitoring the infusion.
Correct Answer: A
Rationale: The correct answer is A. The nurse should compare the current infusion with the prescription and the client's medical record to ensure accuracy and safety. This step is crucial in preventing medication errors and ensuring that the right medication is given to the right patient at the right time. Adjusting the IV infusion rate without verifying the information can lead to potential harm (choice B). Stopping the infusion immediately and notifying the provider is not necessary unless there is a clear indication of a serious issue (choice C). Documenting the discrepancy and continuing monitoring without taking immediate action can compromise patient safety (choice D).
A nurse is providing preoperative teaching to an older adult client who is scheduled for surgery.
Which of the following actions should the nurse take to promote learning?
- A. Speak loudly when addressing the client
- B. Connect new information with the client's past experiences
- C. Present the information to the client using abstract concepts
- D. Use a 12 point font when printing written material for the client
Correct Answer: B
Rationale: The correct answer is B: Connect new information with the client's past experiences. This promotes learning by linking new concepts to existing knowledge, aiding in retention and understanding. Speaking loudly (A) may not enhance learning and can be off-putting. Presenting information abstractly (C) may confuse the client. Using a 12 point font (D) is a formatting preference and does not directly impact learning.
An occupational health nurse is providing teaching to a group of factory workers about proper lifting techniques.
Which statement should the nurse make?
- A. Bend at the waist when lifting objects from the floor.
- B. Keep the object close to your body when lifting.
- C. Twist your torso while lifting to maintain balance.
- D. Lift heavy objects quickly to reduce strain on the muscles.
Correct Answer: B
Rationale: The correct answer is B: Keep the object close to your body when lifting. This statement is correct because keeping the object close to the body reduces the strain on the back muscles and promotes proper lifting mechanics. By keeping the object close, the center of gravity is maintained, reducing the risk of injury.
Incorrect answers:
A: Bending at the waist when lifting can strain the lower back.
C: Twisting the torso while lifting can lead to back injuries.
D: Lifting heavy objects quickly can increase the risk of muscle strains and injuries.