Nokea
A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement, and the nurse offers a bed pan. The client states, 'I've always used the bathroom.' Which of the following responses should the nurse make?
- A. Tell me what concerns you have about using a bed pan.'
- B. Make sure to use nearby furniture to support yourself when walking to the bathroom.'
- C. I will have the physical therapist ambulate you to the bathroom.'
- D. You have to use the bed pan for your own safety.'
Correct Answer: A
Rationale: The correct answer is A: "Tell me what concerns you have about using a bed pan." This response demonstrates therapeutic communication by acknowledging the client's feelings and allowing them to express their concerns. By understanding the client's perspective, the nurse can address specific fears or preferences related to using the bed pan. This approach promotes client autonomy and dignity.
Choice B is incorrect because it disregards the client's expressed need for a bowel movement while on complete bed rest. Choice C is inappropriate as it assumes the client is physically able to be ambulated to the bathroom, which may not be the case. Choice D is incorrect as it is a directive statement that does not address the client's concerns or preferences.
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A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?
- A. Avoid preparing medications for more than two clients at one time
- B. Complete an incident report if a client vomits after taking a medication
- C. Inform clients about the action of each medication prior to administration
- D. Read medication labels at least two times prior to administration
Correct Answer: C
Rationale: The correct answer is C: Inform clients about the action of each medication prior to administration. This is important for promoting patient safety and informed consent. By educating clients about their medications, nurses empower them to be active participants in their own care and help prevent medication errors. Option A is incorrect because preparing medications for multiple clients simultaneously can increase the risk of errors. Option B is incorrect as vomiting after medication administration should be reported to the healthcare provider, not necessarily as an incident report. Option D is incorrect as reading medication labels only once may lead to oversight of important information.
A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?
- A. Tachycardia
- B. Dry cough
- C. Dyspnea
- D. Hypotension
Correct Answer: C
Rationale: The correct answer is C: Dyspnea. Dyspnea in a postoperative client with a history of pulmonary embolism indicates a potential respiratory complication, which could be life-threatening. The priority is to report this finding to the provider for prompt evaluation and intervention to prevent further complications. Tachycardia (A) and hypotension (D) may also be concerning but dyspnea takes precedence due to its association with pulmonary embolism. A dry cough (B) may be a common postoperative symptom and not necessarily urgent.
A nurse is teaching a client about advance directive. Which of the following statements by the client indicates an understanding of the teaching?
- A. A living will is a document that includes my wishes about health care decisions.'
- B. My provider will make my health care decisions if I complete advance directives.'
- C. Advance directives outline who inherits my material possessions in the event of my death.'
- D. My partner needs to be present as a witness when I sign a living will.'
Correct Answer: A
Rationale: The correct answer is A because it accurately defines a living will as a document stating the client's healthcare wishes. This shows understanding of an advance directive's purpose. Option B is incorrect because advance directives empower the client, not the provider, to make healthcare decisions. Option C is incorrect as advance directives focus on healthcare, not material possessions. Option D is incorrect as witnesses don't need to be partners, just competent adults.
A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.'
- B. I can visit my nephew who has chickenpox 5 days after the sores have crusted'
- C. I can clean my cat's litter box during my pregnancy.'
- D. I should wash my hands for 10 seconds with hot water after working in the garden.'
Correct Answer: B
Rationale: The correct answer is B: "I can visit my nephew who has chickenpox 5 days after the sores have crusted." This response indicates understanding of infection prevention because chickenpox is contagious until the sores crust over completely, which usually takes about 5-7 days. Visiting the nephew after this period reduces the risk of contracting the virus.
Incorrect options:
A: Taking antibiotics for a virus is ineffective as antibiotics only work against bacterial infections, not viruses.
C: Cleaning a cat's litter box can expose pregnant individuals to toxoplasmosis, a parasitic infection harmful to the fetus.
D: Washing hands for only 10 seconds with hot water is insufficient to effectively remove germs. The CDC recommends washing for at least 20 seconds with soap and water.
A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender?
- A. The client has a history of alcohol use disorder
- B. The client has a history of asthma.
- C. The client takes vitamin C daily
- D. The client takes furosemide twice daily
Correct Answer: B
Rationale: The correct answer is B. Lavender oil can exacerbate asthma symptoms due to its potential to irritate the respiratory system. Asthma is a contraindication because it can trigger or worsen asthma attacks. Alcohol use disorder (A), vitamin C intake (C), and furosemide use (D) are not contraindications for using lavender oil. Alcohol use disorder does not directly interact with lavender oil. Vitamin C intake and furosemide use do not have known interactions with lavender oil that would contraindicate its use.