Nokea
A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify her religious preferences?
- A. Do you receive Holy Communion?
- B. Do you follow a kosher diet?
- C. Do you consume pork products?
- D. Do you oppose receiving a blood transfusion if necessary?
Correct Answer: C
Rationale: The correct answer is C: Do you consume pork products? This question is relevant for a client practicing Islam as pork consumption is prohibited in Islam. Asking about pork consumption helps the nurse understand and respect the client's religious beliefs.
Incorrect answers:
A: Do you receive Holy Communion? - This question is related to Christian practices, not Islam.
B: Do you follow a kosher diet? - This question is related to Jewish dietary laws, not specific to Islam.
D: Do you oppose receiving a blood transfusion if necessary? - While some religious beliefs may affect views on blood transfusions, this question does not specifically address Islamic beliefs.
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A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
- A. Hypertension
- B. Fibromyalgia
- C. Renal calculi
- D. Fibrocystic breast disease.
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to combination oral contraceptive use due to the increased risk of cardiovascular events. The estrogen component in oral contraceptives can further elevate blood pressure, leading to complications. Other choices like B: Fibromyalgia, C: Renal calculi, and D: Fibrocystic breast disease are not contraindications for oral contraceptive use. Fibromyalgia is a chronic pain condition unrelated to oral contraceptives. Renal calculi are kidney stones, which do not directly affect the safety of oral contraceptives. Fibrocystic breast disease is a benign condition and not a contraindication to oral contraceptives.
A nurse in a provider's office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment?
- A. Hypertension
- B. Obesity
- C. Hypothyroidism
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. Acupuncture involves inserting needles into specific points on the body to alleviate pain. Herpes zoster, also known as shingles, is a viral infection that causes a painful rash. The presence of open sores or active infection in the area where acupuncture needles would be inserted can lead to complications such as spreading the virus or causing pain. Therefore, it is contraindicated to receive acupuncture treatment when a client has active herpes zoster.
Hypertension (A), obesity (B), and hypothyroidism (C) are not contraindications for acupuncture treatment. Hypertension may actually benefit from acupuncture as it can help reduce stress and improve circulation. Obesity and hypothyroidism do not pose any direct risks for receiving acupuncture treatment.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Oliguria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, there is inflammation of the glomeruli in the kidneys, leading to blood in the urine. This is due to damage to the glomerular capillaries allowing red blood cells to leak into the urine. Oliguria (A) is not a common finding as there is usually normal to increased urine output. Hypotension (B) is not typically seen as glomerulonephritis can lead to fluid overload and hypertension. Weight loss (C) is unlikely as fluid retention is common. Hematuria (D) is the hallmark finding due to the damage to glomeruli.
A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who is ambulatory and receiving oxygen
- B. A client who has a fracture and is in balance suspension traction
- C. A client who is bedridden and wears a hearing aid
- D. A client who uses a wheelchair and is confused
Correct Answer: A
Rationale: The correct answer is A: A client who is ambulatory and receiving oxygen should be evacuated first during a fire. This client has the highest risk due to the combination of mobility impairment and oxygen use, which increases the potential for rapid deterioration in a fire emergency. Oxygen supports combustion, making this client more vulnerable to fire-related injuries.
Choice B: A client with a fracture in balance suspension traction is stable and can wait for evacuation. Choice C: A bedridden client with a hearing aid can still hear evacuation instructions and wait for assistance. Choice D: A confused client in a wheelchair may require assistance but is not at immediate risk like the ambulatory client with oxygen.
A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?
- A. Choose a vein that is palpable and straight.
- B. Elevate the client's arm prior to insertion.
- C. Apply a tourniquet below the venipuncture site.
- D. Select a site on the client's dominant arm.
Correct Answer: A
Rationale: Correct Answer: A. Choose a vein that is palpable and straight.
Rationale: Selecting a palpable and straight vein ensures successful insertion and reduces the risk of complications like infiltration or phlebitis. A straight vein allows for easier catheter insertion and reduces the chance of vein damage. Palpability helps in accurately locating the vein for successful cannulation.
Summary of Other Choices:
B: Elevating the client's arm may help distend the veins, but it is not a necessary step for IV catheter insertion.
C: Applying a tourniquet below the venipuncture site can help visualize veins better but is not crucial for successful IV catheter insertion.
D: Selecting the site on the client's dominant arm is not necessary. The nurse should choose the best vein regardless of the arm dominance to ensure successful cannulation.