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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 Saturday as a holy day of rest and worship, known as the Sabbath. By avoiding scheduling diagnostic tests on Saturdays, the nurse respects the client's religious beliefs and practices. This intervention promotes culturally sensitive care by acknowledging and accommodating the client's spiritual needs.
Choice B (Arrange for him to receive the sacrament of the sick) is incorrect as this intervention is specific to the Catholic faith, not Seventh-Day Adventist beliefs. Choice C (Assign same-gender caregivers) is not directly related to the client's religious preferences and may not be necessary for providing culturally sensitive care in this context. Choice D (Offer him a kosher dietary menu) is more aligned with Jewish dietary laws, which do not specifically apply to Seventh-Day Adventist beliefs.
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A client is receiving oxygen therapy via a nasal cannula. When the client asks the nurse why he needs to have oxygen tubing in his nose, which of the following explanations about the cannula should the nurse give him?
- A. It delivers a specific concentration of oxygen constantly.
- B. It delivers the highest concentration of oxygen possible.
- C. It delivers the low concentration of oxygen you need.
- D. It allows you to remove it for a while when it gets uncomfortable.
Correct Answer: C
Rationale: The correct answer is C: It delivers the low concentration of oxygen you need. Nasal cannulas deliver a low flow rate of oxygen, typically between 1-6 liters per minute, providing a lower concentration of oxygen compared to other oxygen delivery devices. This is suitable for clients who require only a slight increase in their oxygen levels. Choice A is incorrect as nasal cannulas do not deliver a specific concentration of oxygen constantly. Choice B is incorrect as nasal cannulas do not deliver the highest concentration of oxygen possible. Choice D is incorrect because nasal cannulas should not be removed when uncomfortable as it disrupts the oxygen therapy.
A nurse is performing tracheostomy care for a client. Which of the following actions should the nurse take?
- A. Use medical aseptic technique.
- B. Clean the inner cannula with mild soap and water.
- C. Secure new tracheostomy ties before removing old ones.
- D. Apply petroleum jelly to the peristomal skin.
Correct Answer: C
Rationale: Securing new tracheostomy ties before removing old ones prevents accidental displacement. Medical asepsis is insufficient; sterile technique is required.
A nurse is reinforcing teaching with a client who has fibrocystic breast changes about dietary changes that can help minimize symptoms. Which of the following dietary elements should the nurse instruct the client to limit?
- A. Fat
- B. Water
- C. Calcium
- D. Vitamin E
Correct Answer: A
Rationale: A diet low in fat has been shown to help reduce fibrocystic breast pain and discomfort.
A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse ask to promote this discussion?
- A. What brought you to the hospital?
- B. Would you tell me about all of your medical issues?
- C. Do you want to talk about your health concerns?
- D. Would it help to discuss your feelings about this hospitalization?
Correct Answer: A
Rationale: The correct answer is A: "What brought you to the hospital?" This question is open-ended and allows the client to share their reason for seeking care, which can provide valuable information for the nurse to understand the client's current health status and concerns. It also helps establish rapport and encourages the client to share their perspective.
Rationale for other choices:
B: Asking about all medical issues is too broad and may overwhelm the client, leading to a less focused discussion.
C: Asking if the client wants to talk about health concerns puts the onus on the client to bring up topics, which may hinder open communication.
D: While discussing feelings is important, it may not be the most immediate priority during admission and may not capture the primary reason for seeking care.
A nurse is caring for a client who has a prescription for a stool guaiac test. The client asks the nurse about the purpose of the test. The nurse should respond by stating that the stool guaiac is testing for which of the following findings in the client's feces?
- A. Bacteria
- B. Parasites
- C. Blood
- D. Fat
Correct Answer: C
Rationale: The correct answer is C: Blood. A stool guaiac test is used to detect the presence of occult (hidden) blood in the feces, which may indicate gastrointestinal bleeding. This test helps in diagnosing various gastrointestinal conditions such as ulcers, polyps, or colorectal cancer. Detecting blood in the stool is crucial for early diagnosis and intervention. Choices A, B, and D are incorrect as stool guaiac test specifically looks for blood, not bacteria, parasites, or fat in the feces. Blood in the stool is a significant finding that requires further investigation, making it the appropriate response in this scenario.