Nokea
A nurse is caring for a client who is unconscious. With the help of an assistive personnel, the nurse has repositioned the client from a left lateral to a right lateral position. The client's daughter asks why the nurse keeps her father lying on his side. Which of the following rationales should the nurse give the family member?
- A. To allow full extension of the hip and knee joints
- B. To prevent aspiration problems
- C. To promote lung expansion
- D. To prevent abdominal distention
Correct Answer: B
Rationale: The correct answer is B: To prevent aspiration problems. When a client is lying on their side, it helps prevent the pooling of secretions in the back of the throat, reducing the risk of aspiration. This is crucial for unconscious clients who may have difficulty protecting their airway.
Choice A is incorrect because lying on the side does not specifically relate to the extension of hip and knee joints. Choice C is incorrect as lying on the side does not directly promote lung expansion. Choice D is incorrect as lying on the side does not prevent abdominal distention.
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A client who is about to undergo hip arthroplasty tells the nurse she is afraid of not receiving adequate anesthesia during the procedure. Which of the following is an appropriate response?
- A. I will call the anesthesiologist right away.
- B. Can you tell me more about this concern?
- C. You have nothing to be concerned about. You have a competent anesthesiologist.
- D. I had a similar procedure and definitely received enough anesthesia.
Correct Answer: B
Rationale: Asking the client to elaborate allows for exploration of their concerns and reassurance through proper information.
A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?
- A. Lower the height of the solution container.
- B. Encourage the client to bear down.
- C. Allow the client to expel some fluid before continuing.
- D. Stop the enema and document that the client did not tolerate the procedure.
Correct Answer: A
Rationale: Correct Answer: A: Lower the height of the solution container.
Rationale: Lowering the height of the solution container will decrease the rate of flow, reducing the pressure and volume of the solution entering the client's colon. This can help alleviate the cramping sensation by slowing down the administration of the enema.
Summary of other choices:
B: Encouraging the client to bear down may increase intra-abdominal pressure, worsening the cramping sensation.
C: Allowing the client to expel some fluid before continuing may not address the root cause of the discomfort, which is the rapid influx of solution.
D: Stopping the enema and documenting that the client did not tolerate the procedure does not actively address the client's discomfort or provide immediate relief.
A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?
- A. Position the client supine.
- B. Have the client bear down during removal.
- C. Cleanse the perineal area with an antiseptic.
- D. Deflate the balloon halfway and then pull out the catheter.
Correct Answer: A
Rationale: The correct answer is A: Position the client supine. This position allows for easier access to the urinary catheter and minimizes the risk of spillage or contamination. Supine position also provides better comfort and stability for the client during the catheter removal process.
Summary of other choices:
B: Having the client bear down during removal can increase the risk of injury and discomfort.
C: Cleaning the perineal area with an antiseptic is important but should be done after removing the catheter.
D: Deflating the balloon halfway and pulling out the catheter can cause pain and discomfort for the client and may lead to trauma.
A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse use as a primary source of accurate data about the client?
- A. Client concerns
- B. Family information
- C. Medical history
- D. Progress note
Correct Answer: A
Rationale: The correct answer is A: Client concerns. This is because the client themselves is the primary source of information about their own health and well-being. By directly listening to the client's concerns, the nurse can gather accurate and firsthand information. Family information (B) may be helpful but is secondary to the client's own input. Medical history (C) is important but may not always reflect the current situation. Progress notes (D) are valuable but are based on observations and interpretations by healthcare providers. Therefore, relying on the client's concerns ensures the most accurate and up-to-date information for the admission process.
A nurse receives a client's laboratory results and notes a potassium level of 3.1 mEq/L. When reviewing the client's medication administration record, which of the following types of medication should the nurse identify as a contributing factor to the client's electrolyte imbalance?
- A. Corticosteroids
- B. NSAIDs
- C. ACE inhibitors
- D. SSRIs
Correct Answer: A
Rationale: Corticosteroids can cause potassium loss through increased renal excretion, leading to hypokalemia.