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A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse, 'I am afraid to have this procedure.' Which of the following responses should the nurse make?
- A. Are you afraid of needles that will be used during the procedure?'
- B. After this procedure, you will feel much better.'
- C. Tell me why you are scared to have this procedure.'
- D. Let's discuss your concerns about this procedure.'
Correct Answer: D
Rationale: Rationale: Option D is correct as it acknowledges the client's fear and opens the door for a discussion about their concerns, allowing the nurse to address them. It shows empathy and promotes client-centered care. Option A focuses solely on needles, which may not address the client's overall fear. Option B dismisses the client's feelings without addressing their fear. Option C asks for the reason but may not actively engage in addressing the fear. Overall, option D is the best choice as it demonstrates active listening and a willingness to address the client's specific concerns.
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A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following statements made by the client indicates an understanding of the teaching?
- A. I can take another dose after 2 minutes.'
- B. I can put the tablet against my cheek and gum.'
- C. I should chew the tablet before I swallow it.'
- D. I should take this medication as soon as the pain begins.'
Correct Answer: A
Rationale: The correct answer is A: "I can take another dose after 2 minutes." This statement indicates an understanding of the teaching because sublingual nitroglycerin is typically used for acute chest pain relief due to angina, and the client should take another dose if the pain persists after 5 minutes, up to a total of 3 doses at 5-minute intervals. This is crucial for managing angina attacks effectively.
Choice B is incorrect because the tablet should be placed under the tongue, not against the cheek and gum. Choice C is incorrect because the tablet should not be chewed but allowed to dissolve under the tongue. Choice D is incorrect because nitroglycerin should be taken at the onset of chest pain, not after the pain begins, for optimal efficacy.
A nurse is planning to withdraw medication from an ampule to prepare for an injection. Which of the following actions should the nurse plan to take?
- A. Withdraw the medication from the ampule using a needleless system.
- B. Place a paper towel around the ampule's neck to break off the top with both hands.
- C. Dispose of the top of the ampule in a sharps container.
- D. Expel air into the ampule to aspirate air bubbles.
Correct Answer: B
Rationale: The correct answer is B: Place a paper towel around the ampule's neck to break off the top with both hands. This method helps prevent injury as the paper towel provides grip and protection. Breaking the ampule's top with both hands reduces the risk of glass shards. Using a needleless system (A) is not necessary for breaking an ampule. Disposing the top in a sharps container (C) is important, but it is not the immediate action for withdrawing medication. Expelling air into the ampule (D) is unnecessary and may introduce air bubbles into the medication.
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
- A. Weight gain
- B. Distended abdomen
- C. Confusion
- D. Dyspnea
Correct Answer: C
Rationale: The correct answer is C: Confusion. In left-sided heart failure, decreased cardiac output can lead to decreased perfusion to the brain, resulting in confusion. Weight gain (A) is more indicative of fluid retention, distended abdomen (B) is a sign of ascites or abdominal organ enlargement, and dyspnea (D) is a common symptom of heart failure but not a direct indicator of decreased cardiac output.
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?
- A. Palpable thrill
- B. Memorantake blood pressure
- C. Absence of a bruit
- D. Dilated appearance of the graft
Correct Answer: A
Rationale: The correct answer is A: Palpable thrill. A palpable thrill indicates that there is adequate circulation of the arteriovenous graft. A thrill is a vibration felt over the graft site, which suggests that blood is flowing through the graft properly. A palpable thrill is a positive sign of good circulation.
The other choices are incorrect because:
B: Membranous blood pressure does not provide information about the circulation of the graft.
C: Absence of a bruit could indicate decreased or absent blood flow through the graft.
D: Dilated appearance of the graft does not necessarily indicate adequate circulation; it could be due to other reasons such as infection or inflammation.
A nurse is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?
- A. Move client to a double room.
- B. Use chemical restraints at bedtime.
- C. Use a bed alarm.
- D. Encourage participation in activities that provide excessive stimulation.
Correct Answer: C
Rationale: The correct answer is C: Use a bed alarm. This option promotes client safety by alerting the nurse when the client attempts to leave the bed, reducing the risk of wandering. Moving the client to a double room (A) does not address the wandering behavior. Using chemical restraints (B) is unethical and can lead to adverse effects. Encouraging excessive stimulation (D) can escalate agitation and wandering behavior.