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A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?
- A. Latex
- B. Seafood
- C. Bee stings
- D. Peanuts
Correct Answer: A
Rationale: Correct Answer: A (Latex)
Rationale: Latex allergies can lead to severe reactions, including anaphylaxis, if the client comes into contact with latex during IV therapy. It is crucial to inform the charge nurse to ensure alternative materials are used to prevent a life-threatening allergic reaction.
Summary of other choices:
B: Seafood - While seafood allergies are common, they are not directly related to IV therapy unless the IV solution contains seafood-derived components.
C: Bee stings - Bee sting allergies are important but are not directly relevant to IV therapy unless there is a risk of exposure during the procedure.
D: Peanuts - Peanut allergies are significant but do not pose a direct threat during IV therapy unless peanuts are present in the IV solution or equipment.
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A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?
- A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client.
- B. Determine the reasons why the client is refusing to use the incentive spirometer.
- C. Document the client’s refusal to participate in health restorative activities.
- D. Administer a pain medication to the client.
Correct Answer: B
Rationale: The correct answer is B: Determine the reasons why the client is refusing to use the incentive spirometer. This is the priority because understanding the client's concerns or barriers to using the spirometer allows the nurse to address them effectively, promote the client's recovery, and prevent complications such as pneumonia. Requesting a respiratory therapist (A) can be helpful, but understanding the client's reasons comes first. Documenting refusal (C) is important but does not address the immediate need to assess and intervene. Administering pain medication (D) may provide temporary relief but does not address the root cause of refusal.
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?
- A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client.
- B. Determine the reasons why the client is refusing to use the incentive spirometer.
- C. Document the client's refusal to participate in health restorative activities.
- D. Administer a pain medication to the client.
Correct Answer: B
Rationale: The correct answer is B: Determine the reasons why the client is refusing to use the incentive spirometer. The priority is to assess the client's reasons for refusal to address any barriers preventing compliance, such as fear, pain, or lack of understanding. Understanding the client's perspective can help tailor interventions and address concerns effectively. Requesting a respiratory therapist (choice A) or administering pain medication (choice D) can be secondary once the client's reasons are identified. Simply documenting the refusal (choice C) without addressing the underlying cause does not promote client-centered care.
A nurse is admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make?
- A. We can initiate medical care until you get legal assistance in preparing your advance directives.
- B. Advance directives can be signed without legal representation.
- C. Advance directives can be a verbal agreement between you and your provider until legal review can be obtained.
- D. A social worker will assist you to find affordable legal representation.
Correct Answer: B
Rationale: Correct Answer: B - Advance directives can be signed without legal representation.
Rationale: Advance directives do not require legal representation to be valid. They are legal documents that outline a person's healthcare wishes in case they are unable to communicate. These documents can be completed by the individual themselves, without the need for a lawyer. By choosing option B, the nurse can provide accurate information and alleviate the client's concerns about the cost of legal representation.
Incorrect Choices:
A: Initiating medical care without advance directives may not align with the client's wishes.
C: Verbal agreements are not legally binding for advance directives.
D: While a social worker can provide resources, legal representation may not be necessary for advance directives.
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
- A. Instruct the client to lift her chin when swallowing.
- B. Talk with the client during her feeding.
- C. Sit at or below the client's eye level during feedings.
- D. Discourage the client from coughing during feedings.
Correct Answer: C
Rationale: The correct answer is C: Sit at or below the client's eye level during feedings. This position helps promote proper swallowing mechanics and reduces the risk of aspiration in clients with dysphagia. Sitting at or below eye level encourages proper head positioning and coordination during swallowing. Choices A and B are incorrect as they do not directly address the physical positioning needed for safe feeding. Choice D is incorrect as coughing during feedings can help prevent aspiration.
A nurse is caring for a client who has been admitted to the hospital. Select the 5 actions the nurse should take?
- A. Provide frequent rest periods for the client
- B. Restrict the client's sodium intake
- C. Advise the client to avoid the use of soap and alcohol-based lotions.
- D. Place the client on a low-carbohydrate diet
- E. Instruct the client to avoid blowing their nose forcefully
- F. Assess the client's level of orientation.
Correct Answer: A,B,C,E,F
Rationale: The correct actions for the nurse to take are A, B, C, E, and F. Providing rest periods (A) promotes healing and recovery. Restricting sodium intake (B) is important for certain conditions like hypertension. Advising the client to avoid soap and alcohol-based lotions (C) can prevent skin irritation. Instructing the client to avoid blowing their nose forcefully (E) prevents potential harm to nasal passages. Assessing the client's level of orientation (F) is crucial for monitoring mental status and detecting any changes. These actions prioritize the client's well-being, safety, and overall health.