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A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?
- A. An angiocatheter
- B. A 25-gauge needle
- C. A butterfly needle
- D. A non-coring needle
Correct Answer: D
Rationale: The correct answer is D: A non-coring needle. This type of needle is specifically designed for accessing implanted venous access ports as it minimizes the risk of coring (removal of a piece of the septum) which can lead to complications. Using an angiocatheter (choice A) or a butterfly needle (choice C) can increase the risk of coring, causing damage to the port. A 25-gauge needle (choice B) is too small for accessing the port effectively. In summary, the non-coring needle is the optimal choice for accessing the port safely and effectively, while the other options pose risks of coring or inefficiency.
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A nurse is talking with an older adult client who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I'm not sure I want to retire.' Which of the following responses should the nurse make?
- A. You would have so much more time to spend with your family.'
- B. You should consider getting a part-time job or doing volunteer work.'
- C. Let's talk about how the change in your job status will affect you.'
- D. Why wouldn't you want to retire and relax?'
Correct Answer: C
Rationale: The correct response is C: "Let's talk about how the change in your job status will affect you." This response acknowledges the client's feelings and initiates a discussion about the potential impact of retirement on their well-being. It shows empathy and encourages open communication, allowing the nurse to explore the client's concerns and fears about retirement. This approach promotes client-centered care and helps the nurse understand the client's perspective better.
Choices A, B, and D are incorrect because they do not address the client's feelings or concerns directly. Option A assumes the client's main motivation for retirement is to spend time with family, which may not be the case. Option B and D provide suggestions without first understanding the client's thoughts and emotions, potentially dismissing their feelings. It is essential to prioritize the client's autonomy and individual needs in such discussions.
A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client, 'If you don't eat, I'll put restraints on your wrists and feed you.' The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
- A. Battery
- B. Assault
- C. Negligence
- D. Malpractice
Correct Answer: B
Rationale: The correct answer is B: Assault. Assault is the threat of harmful or offensive contact without the actual contact occurring. In this scenario, the AP's statement of putting restraints on the client and force-feeding them constitutes a threat of harm, which is considered assault. This is inappropriate behavior and violates the client's autonomy. Battery (choice A) involves actual harmful or offensive contact, which is not present in this situation. Negligence (choice C) refers to a failure to exercise reasonable care, which is not applicable here. Malpractice (choice D) involves professional negligence or misconduct, which is also not relevant in this context.
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.
nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? (You will find hot spots to select in the artwork belowi. Select only the hot spot that corresponds to your answer.)
- A. A
- B. B
- C. C
- D. D
Correct Answer:
Rationale: Correct Answer: B
Rationale: Crackles in pneumonia are typically heard in the lower lung fields due to fluid accumulation. Auscultating at location B (lower anterior chest wall) allows for better detection of crackles in the bases of the lungs where pneumonia commonly affects. This area corresponds to the lower lobes where consolidation occurs, leading to crackles. Auscultating at other locations (A, C, D) may not yield clear crackle sounds associated with pneumonia.
Summary of other choices:
A (Location A - upper anterior chest wall): Crackles in pneumonia are typically heard in the lower lung fields due to fluid accumulation.
C (Location C - middle anterior chest wall): Crackles in pneumonia are not typically heard in the middle lung fields.
D (Location D - upper lateral chest wall): Crackles in pneumonia are not typically heard in the upper lateral chest wall.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Oliguria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, inflammation of the glomeruli causes blood to leak into the urine, resulting in hematuria. This is a classic sign of the condition. Oliguria (A) is decreased urine output, not typically associated with glomerulonephritis. Hypotension (B) is not a common finding as fluid retention is more likely. Weight loss (C) is not a typical symptom, as fluid retention and edema are more common. In summary, hematuria is the hallmark sign of acute glomerulonephritis, distinguishing it from the other choices.