Nokea
A nurse is caring for a client who is about to undergo exploratory surgery to remove a malignant tumor and to determine the extent of any metastasis. The client tells the nurse that she is not hopeful that she will recover and begins to cry. Which of the following responses should the nurse make?
- A. Reassure the client that the provider will use advanced medical knowledge to treat any further problems with her tumor.
- B. Sit quietly with the client and follow her cues.
- C. Suggest that the client discuss her fears with the provider.
- D. Gently change the subject to something more positive.
Correct Answer: B
Rationale: Providing silent support and allowing the client to express emotions promotes emotional well-being.
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A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse use as a primary source of accurate data about the client?
- A. Client concerns
- B. Family information
- C. Medical history
- D. Progress notes
Correct Answer: A
Rationale: The correct answer is A: Client concerns. The primary source of accurate data about the client should always be the client themselves. Clients are the most reliable sources of information regarding their own health, symptoms, and preferences. By directly asking the client about their concerns, the nurse can gather accurate and firsthand information. Family information (B) may be helpful but may not always be completely accurate. Medical history (C) and progress notes (D) are important sources of information but may not always reflect the client's current status or concerns. It is crucial to prioritize the client's perspective to ensure personalized and effective care.
A nurse is caring for a client who has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions should the nurse implement?
- A. Obtain a soft mattress for the client's bed.
- B. Position soft pillows against the bottom of the feet.
- C. Use a footboard to maintain dorsiflexion of the feet.
- D. Cross the client's legs at the ankles.
Correct Answer: C
Rationale: The correct answer is C: Use a footboard to maintain dorsiflexion of the feet. This is important for preventing foot drop, a common issue with right-sided paralysis post-CVA. By maintaining dorsiflexion, the nurse helps prevent contractures and promotes proper alignment of the feet. A soft mattress (A) does not address the specific issue of foot drop. Positioning soft pillows against the bottom of the feet (B) may not provide adequate support and dorsiflexion. Crossing the client's legs at the ankles (D) is contraindicated as it can lead to pressure ulcers and further complications.
A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?
- A. Provide the client with a high fiber diet.
- B. Administer a soap-suds enema to cleanse the colon.
- C. Allow the perineal area to air dry after each stool.
- D. Apply an alcohol-free barrier to the perineal area after each stool.
Correct Answer: D
Rationale: An alcohol-free barrier protects the skin from irritation due to frequent stooling.
The family of a client who has died unexpectedly arrives immediately after the death. Which of the following actions should the nurse take?
- A. Ask the family to return after the staff cleans the body.
- B. Perform postmortem care so that the body is prepared for the funeral home.
- C. Have a clergy member present when the family first sees the client.
- D. Allow the family to view the body privately.
Correct Answer: D
Rationale: The correct answer is D: Allow the family to view the body privately. This is important to facilitate the grieving process and provide closure. Allowing the family to view the body privately enables them to say goodbye in their own way and can help them come to terms with the loss. It shows respect for the family's cultural and religious beliefs regarding death and mourning. It also allows for a more personal and intimate experience for the family members.
Choice A is incorrect because asking the family to return after the staff cleans the body may cause unnecessary delays and distress for the family. Choice B is incorrect as performing postmortem care should not take precedence over allowing the family to view the body. Choice C, having a clergy member present, is a supportive gesture but does not address the immediate needs of the family to see the deceased.
A nurse is caring for a client who is unconscious. With the help of an assistive personnel, the nurse has repositioned the client from a left lateral to a right lateral position. The client's daughter asks why the nurse keeps her father lying on his side. Which of the following rationales should the nurse give the family member?
- A. To allow full extension of the hip and knee joints
- B. To prevent aspiration problems
- C. To promote lung expansion
- D. To prevent abdominal distention
Correct Answer: B
Rationale: The correct answer is B: To prevent aspiration problems. When a client is lying on their side, it helps prevent the pooling of secretions in the back of the throat, reducing the risk of aspiration. This is crucial for unconscious clients who may have difficulty protecting their airway.
Choice A is incorrect because lying on the side does not specifically relate to the extension of hip and knee joints. Choice C is incorrect as lying on the side does not directly promote lung expansion. Choice D is incorrect as lying on the side does not prevent abdominal distention.