Nokea
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 priority is to assess the client's reasons for refusal to address any barriers preventing compliance, such as fear, pain, or lack of understanding. Understanding the client's perspective can help tailor interventions and address concerns effectively. Requesting a respiratory therapist (choice A) or administering pain medication (choice D) can be secondary once the client's reasons are identified. Simply documenting the refusal (choice C) without addressing the underlying cause does not promote client-centered care.
You may also like to solve these questions
A nurse is admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make?
- A. We can initiate medical care until you get legal assistance in preparing your advance directives.
- B. Advance directives can be signed without legal representation.
- C. Advance directives can be a verbal agreement between you and your provider until legal review can be obtained.
- D. A social worker will assist you to find affordable legal representation.
Correct Answer: B
Rationale: Correct Answer: B - Advance directives can be signed without legal representation.
Rationale: Advance directives do not require legal representation to be valid. They are legal documents that outline a person's healthcare wishes in case they are unable to communicate. These documents can be completed by the individual themselves, without the need for a lawyer. By choosing option B, the nurse can provide accurate information and alleviate the client's concerns about the cost of legal representation.
Incorrect Choices:
A: Initiating medical care without advance directives may not align with the client's wishes.
C: Verbal agreements are not legally binding for advance directives.
D: While a social worker can provide resources, legal representation may not be necessary for advance directives.
A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
- A. I will wait 15 minutes after drinking coffee to measure my blood pressure.
- B. I will measure my blood pressure while my arm is elevated above my heart.
- C. I should remove constrictive clothing prior to measuring my blood pressure.
- D. I should measure my blood pressure immediately after eating breakfast.
Correct Answer: C
Rationale: The correct answer is C: "I should remove constrictive clothing prior to measuring my blood pressure." This statement indicates an understanding of the teaching because tight clothing can falsely elevate blood pressure readings. Removing constrictive clothing ensures accurate blood pressure measurement.
Choice A is incorrect because waiting after coffee intake is not directly related to proper blood pressure measurement. Choice B is incorrect as elevating the arm above the heart can lead to inaccurate readings. Choice D is incorrect as measuring blood pressure immediately after eating can also provide inaccurate results due to digestion processes affecting blood pressure.
A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?
- A. Using an electronic messaging system to remind clients when to take medications.
- B. Educating clients about contraindications to specific immunizations.
- C. Helping clients understand health screenings covered by their insurance plans.
- D. Providing clients with information about the benefits of exercise.
Correct Answer: A
Rationale: The correct answer is A because using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention. Tertiary prevention focuses on managing and minimizing the impact of a disease or condition to prevent complications or further deterioration. By reminding clients to take their medications, the nurse is helping to prevent disease progression and improve health outcomes.
Choice B, educating clients about contraindications to specific immunizations, is an example of secondary prevention as it aims to detect and treat a disease early to prevent complications.
Choice C, helping clients understand health screenings covered by their insurance plans, is an example of primary prevention as it aims to prevent the onset of a disease or condition.
Choice D, providing clients with information about the benefits of exercise, is also an example of primary prevention as it focuses on promoting overall health and preventing the development of diseases.
A nurse is caring for a client who is immobilized. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs.
- D. Apply an orthotic to the client's foot.
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. Contractures are a common complication in immobilized clients, where muscles and tendons shorten and tighten due to lack of movement. Applying an orthotic to the foot helps maintain proper alignment and prevents the foot from being in a fixed position, thus reducing the risk of contractures. Positioning a pillow under the client's knees (A) may help with comfort but does not directly prevent contractures. Placing a towel roll under the client's neck (B) is unrelated to preventing contractures in the lower extremities. Aligning a trochanter wedge between the client's legs (C) is more for hip alignment and may not directly prevent contractures in the foot.
A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?
- A. A history of being in prison
- B. Experiencing delusions
- C. Male gender
- D. Previous violent behavior
Correct Answer: D
Rationale: The correct answer is D: Previous violent behavior. This is the best predictor of future violence because individuals who have a history of violent behavior are more likely to engage in violent acts in the future. This is based on the principle of past behavior being a strong indicator of future behavior.
A: A history of being in prison is not as strong a predictor as previous violent behavior because not all individuals who have been in prison exhibit violent tendencies.
B: Experiencing delusions may increase the risk of violence, but it is not as strong a predictor as previous violent behavior.
C: Male gender is a risk factor for violence, but it is not as specific or reliable as previous violent behavior.
Therefore, the most accurate predictor of future violence is an individual's history of previous violent behavior.