Nokea
A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?
- A. Place the client on a low-fiber diet
- B. Request a prescription for a mineral oil for the client
- C. Encourage the client to drink cold fluids
- D. Increase the client's fluid intake
Correct Answer: D
Rationale: The correct answer is D: Increase the client's fluid intake. This intervention helps prevent constipation by promoting hydration and softening stool. Adequate fluid intake aids in maintaining bowel motility and preventing hard stools. Low-fiber diet (A) can exacerbate constipation. Mineral oil (B) can lead to complications and should be avoided. Cold fluids (C) may cause discomfort and are not directly related to improving constipation. In summary, increasing fluid intake is the most appropriate intervention to address constipation in a client on bedrest.
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A nurse is gathering evidence-based practice on catheter-associated urinary tract infections (CAUTI). Which of the following roles is the nurse performing?
- A. Researcher
- B. Nurse manager
- C. Case manager
- D. Educator
Correct Answer: A
Rationale: The correct answer is A: Researcher. The nurse is gathering evidence-based practice on CAUTI, which involves conducting research to gather relevant information, analyze data, and draw conclusions based on evidence. This role aligns with the responsibilities of a researcher who systematically investigates a topic to contribute to the body of knowledge. The other choices are incorrect because: B: Nurse managers oversee nursing staff and operations, C: Case managers coordinate patient care, and D: Educators focus on teaching and disseminating knowledge. In this scenario, the nurse's primary role is to gather evidence through research, making option A the most appropriate choice.
A nurse is teaching a client about the Rinne test. Which of the following client statements indicates an understanding of the teaching?
- A. I will wear earphones during this test
- B. A small probe is placed inside my ear
- C. A tuning fork is placed on my head
- D. Small electrodes are placed on my scalp
Correct Answer: C
Rationale: The correct answer is C: A tuning fork is placed on my head. In the Rinne test, a tuning fork is first placed against the client's mastoid bone behind the ear and then moved near the ear canal. The client should hear the sound louder when the fork is near the ear if the test is normal. Choice A is incorrect because earphones are not used in the Rinne test. Choice B is incorrect as a probe is not inserted into the ear. Choice D is incorrect as electrodes are not part of the Rinne test. Placing a tuning fork on the head is the correct step in performing the Rinne test to assess hearing conduction.
A nurse is teaching a client how to walk using a walker. After showing the client the procedure, the nurse asks the client to perform the skill. Which of the following types of teaching strategies is the nurse utilizing?
- A. Role-play
- B. Question-and-answer
- C. Discussion
- D. Return demonstration
Correct Answer: D
Rationale: The correct answer is D: Return demonstration. This teaching strategy involves the client performing the skill back to the nurse to demonstrate understanding and competence. It allows for immediate feedback and correction. Role-play (A) involves acting out a scenario, not necessarily related to skill demonstration. Question-and-answer (B) involves asking and answering questions but does not involve the client performing a skill. Discussion (C) involves exchanging ideas and opinions, not skill demonstration.
A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take first?
- A. Assist the client into a standing position
- B. Check the blood pressure with the client in a supine position
- C. Determine the client's blood pressure 1 min after each position change
- D. Place the client in a sitting position
Correct Answer: B
Rationale: The correct answer is B: Check the blood pressure with the client in a supine position. This is the first action the nurse should take because it establishes the baseline blood pressure of the client in a resting position. Orthostatic hypotension is characterized by a drop in blood pressure upon standing. By measuring the blood pressure in a supine position first, the nurse can accurately assess the extent of the blood pressure change when the client stands up.
Choices A, C, and D are incorrect because they involve positioning changes before establishing the baseline blood pressure. It is crucial to first determine the baseline blood pressure to accurately diagnose orthostatic hypotension. Choice A (Assist the client into a standing position) and D (Place the client in a sitting position) may exacerbate the client's symptoms if orthostatic hypotension is present. Choice C (Determine the client's blood pressure 1 min after each position change) is premature without knowing the baseline blood pressure.
A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
- A. Prepares the sterile field 2 hr before it is needed
- B. Uses a surface that is at waist height
- C. Places the sterile field against a wall in the client's room
- D. Opens the first flap of the sterile package towards the nurse's body
Correct Answer: B
Rationale: The correct answer is B because setting up a sterile field at waist height minimizes the risk of contamination. This position ensures better visibility and accessibility for the nurse while maintaining sterility. Choice A is incorrect as preparing the sterile field too early can lead to contamination. Choice C is incorrect as placing the sterile field against a wall increases the risk of contamination from the wall. Choice D is incorrect because the first flap should be opened away from the body to prevent contamination.