Nokea
A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that her partner brought for her. Which of the following responses should the nurse make?
- A. Does the doctor know you are eating that?
- B. Why are you eating seaweed soup?
- C. Of course, I will heat that up for you.
- D. The hospital food is more nutritious.
Correct Answer: C
Rationale: Respecting cultural preferences and providing client-centered care promotes trust.
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A client with a history of depression is experiencing a situational crisis. Which of the following actions should the nurse take first?
- A. Confirm the client's perception of the event.
- B. Notify the client's support system.
- C. Help the client identify personal strengths.
- D. Teach the client relaxation techniques.
Correct Answer: A
Rationale: The correct answer is to confirm the client's perception of the event. In crisis intervention, understanding the client's perspective is crucial as it helps the nurse assess the situation accurately and provide tailored support. This step can also help build rapport and trust with the client. Option B, notifying the client's support system, may be important but should come after assessing the client's perception. Option C, helping the client identify personal strengths, and option D, teaching relaxation techniques, are valuable interventions but should follow the initial step of confirming the client's perception.
A nurse is providing discharge teaching to a client who has a new prescription for digoxin. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. Take your pulse before taking this medication.
- C. Avoid eating foods high in potassium.
- D. Take this medication with an antacid.
Correct Answer: B
Rationale: The correct instruction for the nurse to include is to advise the client to take their pulse before taking digoxin. This is important to monitor for bradycardia, a potential side effect of the medication. Option A is incorrect because digoxin is usually taken in the morning. Option C is unrelated to digoxin therapy, as high potassium foods are usually restricted in clients taking potassium-sparing diuretics. Option D is incorrect because digoxin should not be taken with antacids as they can affect its absorption.
A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. What should the nurse report?
- A. Chest pain.
- B. Muscle spasms.
- C. Cool, moist skin.
- D. Incisional pain.
Correct Answer: A
Rationale: In this scenario, postoperative chest pain is a critical finding that must be reported promptly. Chest pain after an arterial thrombectomy could indicate serious complications such as myocardial infarction or pulmonary embolism. Muscle spasms and cool, moist skin are not the priority assessments in this situation. Incisional pain is common after surgery and is not typically a cause for immediate concern unless it is severe and accompanied by other symptoms.
A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia. Which of the following actions is the nurse's priority?
- A. Consult with a case manager regarding insurance coverage.
- B. Counsel caregivers on respite care options.
- C. Ensure that the client has a referral for physical therapy.
- D. Refer the client to a local stroke support group.
Correct Answer: C
Rationale: The correct answer is C: 'Ensure that the client has a referral for physical therapy.' For a client with left-sided hemiplegia, physical therapy is crucial in restoring function and mobility. It is the nurse's priority to ensure the client receives the necessary rehabilitation services. Consulting with a case manager about insurance coverage (Choice A) is important but not the priority at this stage. Counseling caregivers on respite care options (Choice B) and referring the client to a local stroke support group (Choice D) are also valuable but not as essential as ensuring the client has access to physical therapy for rehabilitation.
A client with osteoporosis is being taught about dietary management. Which of the following foods should be recommended?
- A. Almonds
- B. Spinach
- C. Yogurt
- D. Carrots
Correct Answer: C
Rationale: Yogurt is a calcium-rich food that helps strengthen bones and should be recommended to clients with osteoporosis. Almonds, spinach, and carrots do not provide as much calcium as yogurt and are not as beneficial for individuals with osteoporosis.