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A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?
- A. Cracks in oral mucous membranes
- B. Poor skin turgor
- C. Tachycardia
- D. Excessive pulmonary secretions
Correct Answer: C
Rationale: Tachycardia can indicate oxygen toxicity. Other symptoms include confusion and restlessness. Pulmonary secretions are expected in pneumonia, not a sign of toxicity.
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A nurse is caring for an older adult client who has dementia and wanders at night. Which of the following interventions should the nurse take?
- A. Assign the client to a quiet room away from the nurses' station.
- B. Elevate the four side rails on the client's bed at night time.
- C. Encourage the client to rest during the day.
- D. Take the client to the bathroom on a regular schedule.
Correct Answer: D
Rationale: The correct answer is D: Take the client to the bathroom on a regular schedule. This is the most appropriate intervention as older adults with dementia may have difficulty expressing their needs and may forget to use the bathroom. Establishing a routine for bathroom breaks can prevent accidents and promote comfort. Choice A is incorrect as isolating the client may increase agitation. Choice B is incorrect as using all four side rails can be a safety hazard and restrict mobility. Choice C is incorrect as it does not address the specific issue of wandering at night.
A nurse is caring for an older adult client who is Chinese and is recovering from a bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which of the following purposes?
- A. To regulate blood pressure
- B. To promote digestion
- C. To enhance the immune system
- D. To reduce inflammation
Correct Answer: B
Rationale: The correct answer is B: To promote digestion. Ginger tea has been traditionally used in Chinese medicine to aid digestion by stimulating the production of digestive enzymes and reducing bloating and gas. This can be particularly beneficial for an older adult recovering from a bowel obstruction as it can help ease the digestive process and prevent further complications. Additionally, ginger has anti-inflammatory properties, which can also be helpful in reducing inflammation in the digestive tract.
Other choices are incorrect:
A: To regulate blood pressure - While ginger may have some benefits for heart health, its primary role in this scenario is to aid digestion, not regulate blood pressure.
C: To enhance the immune system - While ginger may have some immune-boosting properties, the primary reason for the client's request in this case is to aid digestion.
D: To reduce inflammation - While ginger does have anti-inflammatory properties, the main purpose of the client's request is to aid digestion rather than specifically targeting inflammation.
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on affective learning with this client, which of the following interventions should the nurse use?
- A. Ask the client to perform a return demonstration of insulin injection.
- B. Review the action of insulin therapy.
- C. Explore the client's feelings about dietary modifications.
- D. Have a family member practice blood glucose monitoring using a glucometer.
Correct Answer: C
Rationale: The correct answer is C because exploring the client's feelings about dietary modifications focuses on the affective domain of learning, which involves emotions, attitudes, and values. By understanding the client's feelings, the nurse can address any concerns, fears, or resistance the client may have towards changing their diet. This approach helps to create a supportive and empathetic environment for the client to embrace necessary dietary changes.
Regarding the incorrect choices:
A: Asking the client to perform a return demonstration of insulin injection focuses on psychomotor skills, not affective learning.
B: Reviewing the action of insulin therapy focuses on cognitive learning, not affective learning.
D: Having a family member practice blood glucose monitoring is not directly related to addressing the client's emotional response to dietary modifications.
A nurse notes that the left eyelid of a client who is unconscious remains partially open. To protect the eye, which of the following actions should the nurse take?
- A. Irrigate the eye daily with 0.9% sodium chloride irrigation solution.
- B. Dim the lights in the room.
- C. Instill ophthalmic ointment into the lower lid.
- D. Keep the client off her left side.
Correct Answer: C
Rationale: The correct answer is C: Instill ophthalmic ointment into the lower lid. This action helps prevent corneal abrasions by keeping the eye moist and lubricated. Irrigating the eye with saline solution (choice A) may not provide adequate protection. Dimming the lights (choice B) doesn't directly address eye protection. Keeping the client off her left side (choice D) is unrelated to eye care.
A nurse is caring for a client who follows Halal, Islamic dietary laws. The nurse should recognize that the client will practice which of the following dietary practices?
- A. Does not eat meat and dairy products at the same meal.
- B. Does not eat birds of prey.
- C. Refrains from eating snacks between meals.
- D. Does not eat shellfish.
Correct Answer: B
Rationale: Halal dietary laws prohibit the consumption of birds of prey, as they are considered impure.