Nokea
A nurse is contributing to the plan of care for a client who is a Seventh-Day Adventist. To provide spiritually and culturally sensitive care, which of the following interventions should the nurse suggest for this client?
- A. Do not schedule diagnostic tests for Saturday.
- B. Arrange for him to receive the sacrament of the sick.
- C. Assign same-gender caregivers.
- D. Offer him a kosher dietary menu.
Correct Answer: A
Rationale: The correct answer is A: Do not schedule diagnostic tests for Saturday. Seventh-Day Adventists observe the Sabbath on Saturdays and refrain from work or secular activities. By avoiding scheduling diagnostic tests on Saturdays, the nurse respects the client's religious beliefs and promotes culturally sensitive care.
Incorrect options:
B: Arrange for him to receive the sacrament of the sick - This option pertains to a Catholic sacrament, not relevant to Seventh-Day Adventist beliefs.
C: Assign same-gender caregivers - This is related to privacy and modesty, not specific to Seventh-Day Adventist beliefs.
D: Offer him a kosher dietary menu - Kosher dietary laws are specific to Jewish beliefs, not Seventh-Day Adventist practices.
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A nurse in an extended-care facility is reinforcing teaching with a group of newly licensed nurses about the expected physiologic changes of aging. Which of the following information should the nurse include? (Select all that apply.)
- A. More difficulty seeing due to a greater sensitivity to glare
- B. Decreased cough reflex
- C. Decreased bladder capacity
- D. Decreased systolic blood pressure
- E. Dehydration of intervertebral discs
Correct Answer: A,B,C,E
Rationale: Correct Answer: A, B, C, E
Rationale:
A: With aging, the lens of the eye becomes less flexible, leading to difficulty seeing due to glare.
B: Aging affects the cough reflex, making it less effective in clearing the respiratory tract.
C: Bladder capacity decreases with age due to decreased muscle tone and elasticity.
E: Intervertebral discs lose water content with age, leading to dehydration and decreased flexibility.
Incorrect Choices:
D: Systolic blood pressure tends to increase with age, not decrease.
F, G: No information provided to analyze these options.
A newly licensed nurse has obtained a capillary glucose level from a client that produced inaccurate results and reports this to the charge nurse. Which of the following actions should the charge nurse take?
- A. Assign another nurse to be responsible for obtaining capillary glucose levels.
- B. Verify that the newly licensed nurse attended the staff education class about capillary glucose levels.
- C. Repeat the capillary glucose levels.
- D. Recheck the next scheduled capillary glucose level immediately following the nurse's.
Correct Answer: C
Rationale: The correct answer is C: Repeat the capillary glucose levels. This action should be taken to confirm the accuracy of the initial results. By repeating the test, the charge nurse can determine if the inaccuracy was due to a procedural error or if there is an issue with the equipment. This step ensures that the client receives proper care based on accurate information.
Assigning another nurse (choice A) does not address the root cause of the inaccurate results. Verifying attendance at an education class (choice B) is not as immediate or relevant as repeating the test. Rechecking the next scheduled level (choice D) without verifying the accuracy of the initial result may lead to continued inaccuracies in care.
A nurse is collecting data from a client who has ataxia. Which of the following is appropriate to evaluate the client's ability to safely ambulate?
- A. Auscultate for Korotkoff's sounds.
- B. Perform a Romberg test.
- C. Check the function of cranial nerve V.
- D. Inspect for the presence of clubbing.
Correct Answer: B
Rationale: The correct answer is B: Perform a Romberg test. This test evaluates the client's ability to maintain balance with eyes closed, which is essential for safe ambulation in a client with ataxia. Auscultating for Korotkoff's sounds (A) is related to blood pressure assessment, not ambulation. Checking cranial nerve V function (C) is important for facial sensation and chewing, not directly related to ambulation. Inspecting for clubbing (D) is related to respiratory or cardiovascular conditions, not relevant to assessing ambulation.
A nurse is caring for an older adult client who reports occasional constipation. The nurse should inform the client that straining while defecating can cause which of the following?
- A. Dilated pupils
- B. Dysrhythmias
- C. Diarrhea
- D. Gastric ulcer
Correct Answer: B
Rationale: The correct answer is B: Dysrhythmias. Straining while defecating can increase intra-abdominal pressure, leading to a vagal response that triggers dysrhythmias in susceptible individuals. This can be particularly dangerous for older adults with underlying heart conditions. Dilated pupils (choice A) are not directly related to straining during defecation. Diarrhea (choice C) is the opposite of constipation and is not a common consequence of straining. Gastric ulcers (choice D) are typically caused by factors such as H. pylori infection or NSAID use, not straining during defecation.
A nurse is preparing to perform wound care and remove staples from a client's surgical incision following a hip replacement. Identify the sequence the nurse should follow. (Move the steps of staple removal into the box on the right, placing them in the selected order of performance. All steps must be used.)
- A. Remove every other staple.
- B. Wipe cleansing solution directly over the surgical incision.
- C. Remove remaining staples.
- D. Remove the wound dressing.
- E. Clean the skin along the sides of the incision.
Correct Answer: D, E, A, C, B
Rationale: First, remove the wound dressing to expose the incision. Then, clean the skin along the sides to reduce infection risk. Next, remove every other staple to maintain stability before removing the remaining ones. Finally, wipe cleansing solution to keep the site clean.