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A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?
- A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client.
- B. Determine the reasons why the client is refusing to use the incentive spirometer.
- C. Document the client's refusal to participate in health restorative activities.
- D. Administer a pain medication to the client.
Correct Answer: B
Rationale: The correct answer is B: Determine the reasons why the client is refusing to use the incentive spirometer. The nurse's priority is to assess why the client is refusing the treatment to address the underlying issue. By understanding the client's reasoning, the nurse can provide appropriate interventions and education to encourage compliance, ensuring optimal recovery. Requesting a respiratory therapist (A) may be helpful but does not address the client's refusal directly. Documenting the refusal (C) is important but does not actively address the issue. Administering pain medication (D) may provide temporary relief but doesn't address the root cause of refusal.
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The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
- E. Wear a sterile water-resistant gown if within 3 feet of the client.
Correct Answer: A, B, C, E
Rationale: The correct interventions for placing a client on isolation precautions include A, B, C, and E. A) Wearing an N95 mask is crucial for airborne precautions. B) Placing a container for soiled linens inside the room prevents contamination. C) A negative airflow room helps contain airborne pathogens. E) Wearing a sterile water-resistant gown within close proximity to the client prevents transmission. D is incorrect as the mask should be removed inside the client's room. Choices F and G are likely blank options or not relevant to isolation precautions.
A nurse is assessing a client with heart failure. The client reports increasing shortness of breath, fatigue, and weakness. Which of the following findings in the assessment should the nurse identify as most concerning?
- A. Weak pulses with +2 dependent edema in lower extremities.
- B. Slightly labored respirations at rest.
- C. Wheezes and crackles in the chest.
- D. Reports productive cough during the overnight hours.
Correct Answer: C
Rationale: The correct answer is C: Wheezes and crackles in the chest. This finding is most concerning in a client with heart failure as it indicates potential fluid overload in the lungs, leading to impaired gas exchange and worsening respiratory status. Wheezes suggest bronchoconstriction, while crackles indicate fluid accumulation in the alveoli, both of which can exacerbate shortness of breath. Weak pulses with dependent edema (choice A) are expected in heart failure but do not directly point to acute decompensation. Slightly labored respirations at rest (choice B) may be common in heart failure but do not indicate immediate deterioration. Reports of a productive cough (choice D) can be a sign of fluid retention but are less urgent compared to wheezes and crackles.
A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?
- A. Role ambiguity
- B. Sick role
- C. Role overload
- D. Role conflict
Correct Answer: C
Rationale: The correct answer is C: Role overload. Role overload occurs when an individual feels overwhelmed by the demands of multiple roles, leading to stress and difficulty in managing responsibilities. In this scenario, the partner is struggling to balance caring for their partner with dementia and managing household responsibilities, indicating an excessive workload.
A: Role ambiguity refers to uncertainty about expectations and responsibilities in a role, which is not evident in the scenario.
B: Sick role pertains to the behavior and expectations of individuals who are ill, which is not the focus of the partner's stress.
D: Role conflict involves conflicting demands from different roles, which is not the primary issue in this situation.
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?
- A. Is your pain constant or intermittent?
- B. What would you rate your pain on a scale of 0 to 10?
- C. Does the pain radiate?
- D. Is your pain sharp or dull?
Correct Answer: D
Rationale: The correct answer is D: "Is your pain sharp or dull?" This question helps the nurse determine the characteristic of the pain, which is crucial in identifying the underlying cause. Sharp pain is often associated with acute conditions like nerve irritation, whereas dull pain may indicate musculoskeletal issues. Choices A, B, and C are important in pain assessment but do not specifically address the quality of pain. Asking about pain intensity (choice B) or radiation (choice C) can provide valuable information but do not directly address whether the pain is sharp or dull. Therefore, option D is the most appropriate for assessing the quality of the client's pain in this scenario.
A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?
- A. Image A: Client sitting with legs dangling over the edge of the table and the examiner tapping below the patella with a reflex hammer.
- B. Image B: Client lying down with legs extended and the examiner tapping above the patella with a reflex hammer.
- C. Image C: Client sitting with legs crossed while the examiner taps the patella with a reflex hammer.
- D. Image D: Client standing with knees slightly bent while the examiner taps the patella with a reflex hammer.
Correct Answer: A
Rationale: The correct answer is A because the image depicts the correct technique for eliciting the patellar reflex. When assessing the patellar reflex, the client should be sitting with their legs dangling over the edge of the table, and the examiner should tap below the patella with a reflex hammer. This position allows for optimal relaxation of the quadriceps muscle and easy access to the patellar tendon, resulting in a more accurate reflex response.
Choice B is incorrect because tapping above the patella can lead to an inaccurate response as it does not target the patellar tendon directly. Choices C and D are incorrect as they involve incorrect client positions that do not facilitate the proper assessment of the patellar reflex.