Nokea
A nurse is caring for a client who has type I diabetes mellitus and is not adhering to guidelines for therapy. Which of the following factors should the nurse consider as contributing to the nonadherence?
- A. Gender
- B. Culture
- C. Allergies
- D. Dexterity
- E. Motivation
Correct Answer: B,D,E
Rationale: Cultural beliefs, dexterity limitations, and motivation significantly impact adherence to diabetes management.
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A nurse is caring for a client who has a new diagnosis of chronic renal failure. The nurse should recognize which of the following client statements as an indication of anticipatory grief?
- A. I know that I will get a kidney transplant. I am a good candidate.
- B. I can now eat whatever I want. It will be dialyzed out of my system.
- C. I just can't believe that my whole life is going to be ruined by dialysis.
- D. I know that renal failure runs in my family and I can prevent it.
Correct Answer: C
Rationale: The correct answer is C because the statement reflects a sense of loss and mourning over the potential impact of the diagnosis on the client's life. Anticipatory grief involves feelings of sadness, anxiety, and loss before an actual event occurs. Option A shows hope and optimism, not anticipatory grief. Option B indicates a lack of understanding about the seriousness of the condition. Option D demonstrates a focus on prevention rather than grieving.
Which of the following should the nurse recognize as a sign of possible infection in a postoperative client? (Select all that apply.)
- A. Increased urine output
- B. Adventitious breath sounds
- C. Decreased level of consciousness
- D. Dry crust on the incision line
- E. Oral temperature of 38.3°C (101°F)
Correct Answer: B,C,E
Rationale: Adventitious breath sounds suggest pneumonia, decreased consciousness may indicate sepsis, and fever is a systemic infection response. Increased urine output is not a sign, and dry crust is part of normal healing.
A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
- A. Count the apical pulsations for a full minute.
- B. Check the apical pulse with a Doppler device.
- C. Use the diaphragm of the stethoscope to listen to the apical pulsations.
- D. Press the stethoscope firmly against the client's skin.
Correct Answer: A
Rationale: The correct answer is A: Count the apical pulsations for a full minute. This is because counting the apical pulse for a full minute provides the most accurate and reliable measurement of the heart rate, especially in clients taking cardiovascular medications where variations may occur. Checking for a full minute allows the nurse to capture any irregularities or changes in the pulse rhythm.
Choice B is incorrect because using a Doppler device is not necessary for routine assessment of the apical pulse. Choice C is incorrect as the bell of the stethoscope, not the diaphragm, is used to listen to the apical pulse for better sound transmission. Choice D is incorrect as pressing the stethoscope firmly against the skin can distort the sound of the pulse.
A provider is discharging a client with a prescription for home oxygen therapy. The nurse should reinforce which of the following instructions with the client and his family? (Select all that apply.)
- A. Cleanse the mask or collar with soapy water every other day.
- B. Make sure the straps on the mask are secure but not too tight.
- C. Check the tops of his ears regularly for skin breakdown.
- D. Post 'no smoking' warning signs at home in a prominent location.
- E. Apply petroleum jelly around and inside the nares.
Correct Answer: B,C,D
Rationale: Correct Answer: B, C, D
Rationale:
B: Making sure the straps on the mask are secure but not too tight is essential to ensure proper oxygen delivery without discomfort or skin irritation.
C: Checking the tops of the ears regularly for skin breakdown is important as the oxygen tubing can cause pressure and skin breakdown in this area.
D: Posting 'no smoking' warning signs at home in a prominent location is crucial as oxygen is highly flammable and can lead to a fire hazard if exposed to smoking or open flames.
Summary:
A: Cleansing the mask or collar with soapy water every other day is not necessary for home oxygen therapy as frequent cleaning can damage the equipment.
E: Applying petroleum jelly around and inside the nares is not recommended as it can interfere with oxygen delivery and cause respiratory issues.
A nurse in an urgent care clinic is preparing to remove skin sutures from a client. Which of the following actions should the nurse take?
- A. Remove loose sutures first
- B. Cut below the suture knot
- C. Use clean bandage scissors
- D. Lift sutures from the skin with a sterile needle
Correct Answer: B
Rationale: Cutting below the suture knot prevents external contamination and reduces infection risk.