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A nurse is caring for a client who is to undergo surgery the next day. The client tells the nurse, 'I'm afraid of what's going to happen.' Which of the following responses should the nurse make?
- A. Assure the client that the surgery is safe and complications are rare.
- B. Encourage the client to discuss her fears further.
- C. Inform the client that she has an excellent provider and has nothing to worry about.
- D. Explain to the client that anxiety can prolong hospitalization.
Correct Answer: B
Rationale: Encouraging the client to talk about their fears provides emotional support and can reduce anxiety.
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A nurse is caring for a client receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm. Which of the following actions should the nurse perform first?
- A. Insert an IV catheter in the opposite extremity.
- B. Discontinue the existing IV infusion.
- C. Apply warm, moist compresses to the site.
- D. Elevate the extremity.
Correct Answer: B
Rationale: The correct action is to discontinue the existing IV infusion (Choice B) first. The redness, swelling, and warmth at the IV site indicate phlebitis, which is inflammation of the vein. Discontinuing the infusion is crucial to prevent further damage and infection. This step helps to stop the irritant (IV solution) from causing more harm. Inserting an IV catheter in the opposite extremity (Choice A) does not address the current issue and may lead to the same problem. Applying warm, moist compresses (Choice C) could potentially worsen the inflammation. Elevating the extremity (Choice D) may provide some relief, but it does not address the root cause. Therefore, discontinuing the existing IV infusion is the most appropriate immediate action to take in this situation.
A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?
- A. Request that the provider prescribe a stool softener.
- B. Promote active range-of-motion activities.
- C. Add fluid and fiber to the diet.
- D. Avoid gas-producing foods.
Correct Answer: C
Rationale: The correct answer is C: Add fluid and fiber to the diet. Increasing fluid intake helps soften the stool, making it easier to pass. Fiber adds bulk to the stool, promoting regular bowel movements. This is a non-invasive and effective intervention for constipation in older adults. Requesting a stool softener (A) may be considered if dietary interventions are ineffective. Promoting active range-of-motion activities (B) may help prevent constipation but is not the first-line intervention. Avoiding gas-producing foods (D) is not directly related to treating constipation.
A 46-year-old African-American man is in an outpatient clinic for a physical examination. His BP is 126/84 mm Hg, his BMI is 24, and he reports no previous medical problems. Which of the following actions should the nurse take?
- A. Schedule his next appointment for 1 year from now.
- B. Provide information about how to reduce risk factors of hypertension.
- C. Schedule an appointment for a prostate-specific antigen (PSA) test.
- D. Provide information for a weight loss plan that includes increasing physical activity.
Correct Answer: B
Rationale: The correct answer is B: Provide information about how to reduce risk factors of hypertension. This is the appropriate action because the patient, being African-American, is at increased risk for hypertension. Providing information on lifestyle modifications such as a healthy diet, regular exercise, and stress management can help prevent the development of hypertension. This proactive approach aligns with preventative care and promotes the patient's overall well-being.
Choice A is incorrect because annual appointments may not address potential risk factors for hypertension. Choice C, scheduling a PSA test, is not relevant to the patient's current health assessment. Choice D, providing a weight loss plan, may be beneficial but not directly related to hypertension risk reduction in this scenario.
A nurse is assisting with the admission of a client who is hyperventilating, reports lightheadedness and paresthesias, and has blurred vision and a new onset of confusion. The nurse should suspect that the client has developed which of the following imbalances?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: The correct answer is D, respiratory alkalosis. Hyperventilation causes excessive loss of carbon dioxide, leading to respiratory alkalosis. This is evidenced by lightheadedness, paresthesias, blurred vision, and confusion due to decreased carbon dioxide levels in the blood. Metabolic acidosis (A) is characterized by low pH and bicarbonate levels, not seen in this scenario. Metabolic alkalosis (B) is due to excess bicarbonate, which is not present in hyperventilation. Respiratory acidosis (C) is caused by retention of carbon dioxide, opposite of what is seen in hyperventilation.
A nurse is caring for a client who practices Orthodox Judaism. The nurse should identify that which of the following foods together on the same dinner tray violates the client's religious practices?
- A. Kosher roast beef and ice cream
- B. Carrot sticks and cottage cheese
- C. Macaroni and cheese
- D. Kosher chicken breast and boiled potatoes
Correct Answer: A
Rationale: The correct answer is A: Kosher roast beef and ice cream. In Orthodox Judaism, meat and dairy products cannot be consumed together. Kosher laws prohibit mixing meat and dairy in the same meal or on the same plate to maintain dietary restrictions. Choices B, C, and D do not violate this rule as they do not mix meat and dairy products. Carrot sticks and cottage cheese (B), macaroni and cheese (C), and kosher chicken breast and boiled potatoes (D) are all permissible combinations in Orthodox Judaism.