Nokea
A nurse is observing an assistive personnel (AP) who is preparing to deliver a meal tray to a client who practices Orthodox Judaism. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?
- A. Allow the AP to deliver the food tray to the client.
- B. Call the dietary department and ask for a kosher meal tray.
- C. Replace the nonfat milk with apple juice.
- D. Explain to the client that he needs the protein in the milk and the beef.
Correct Answer: B
Rationale: Orthodox Jewish dietary laws prohibit consuming dairy and meat together, so a kosher meal should be requested.
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A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?
- A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.
- B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
- C. Include intact skin at the wound edges in the culture.
- D. Swab an area of skin away from the wound to identify normal flora.
Correct Answer: A
Rationale: The correct answer is A: Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen. This step is essential to remove debris and contaminants from the wound, ensuring that the specimen obtained is not contaminated. Cleansing with a normal saline solution helps to minimize the risk of introducing outside pathogens into the culture sample. It also helps to provide a more accurate representation of the microorganisms present specifically within the wound.
Choices B, C, and D are incorrect. Choice B suggests using an antiseptic, which may interfere with the accuracy of the culture results. Choice C is incorrect because intact skin should not be included in the culture sample, as it does not reflect the microorganisms present in the wound. Choice D is incorrect as swabbing an area away from the wound will not provide relevant information about the wound infection.
A nurse is caring for an older adult client who expresses feelings of grief for his earlier life. Which of the following actions should the nurse take to help the client cope with his feelings of loss?
- A. Let the client know that this is a common problem of the aging population.
- B. Provide the client with activities to perform so he won't have time to dwell on the past.
- C. Listen attentively when the client talks about the past.
- D. Tell the client about some of the younger clients in the hospital who have experienced loss.
Correct Answer: C
Rationale: The correct answer is C. Listening attentively when the client talks about the past is essential in helping the older adult cope with feelings of grief. By actively listening, the nurse validates the client's feelings and provides a supportive environment for the client to express and process their emotions. This approach shows empathy and understanding, which can help the client feel heard and respected.
Choice A is incorrect because simply stating that it is a common problem does not address the client's individual feelings and may diminish the significance of their grief. Choice B is incorrect as it suggests avoidance rather than addressing the client's emotions directly. Choice D is incorrect as comparing the client's experience to that of younger clients may not be relevant or helpful.
A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?
- A. Brachial
- B. Carotid
- C. Femoral
- D. Popliteal
Correct Answer: B
Rationale: The correct answer is B: Carotid. Checking the carotid pulse bilaterally simultaneously can lead to a temporary decrease in blood flow to the brain, potentially causing dizziness or fainting. It is important to assess one carotid pulse at a time to ensure adequate blood supply to the brain. Checking the brachial, femoral, and popliteal pulses bilaterally at the same time is safe as it does not pose a risk of compromising blood flow to critical organs.
A nurse is reinforcing teaching with a client who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
- A. Excessive laxative use
- B. Ignoring the urge to defecate
- C. Inadequate fluid intake
- D. Increased fiber in the diet
- E. Increased activity
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. A: Excessive laxative use can lead to constipation by causing dependency on laxatives. B: Ignoring the urge to defecate can disrupt the normal bowel movement pattern, leading to constipation. C: Inadequate fluid intake can result in hard, dry stools that are difficult to pass, causing constipation. D: Increased fiber in the diet actually helps prevent constipation by adding bulk to the stool. E: Increased activity generally promotes bowel regularity and helps prevent constipation. By discussing A, B, and C with the client, the nurse can address common causes of constipation and provide appropriate interventions.
A nurse is observing the IV catheter insertion site of a client who is receiving continuous IV therapy. Which of the following manifestations should the nurse identify as an indication that the client has developed phlebitis?
- A. Erythema
- B. Pallor
- C. Coolness
- D. Drainage
Correct Answer: A
Rationale: The correct answer is A: Erythema. Phlebitis is inflammation of the vein, which commonly presents with redness (erythema) at the site. This is due to the body's response to the irritation caused by the IV catheter. Pallor (choice B) and coolness (choice C) are not typical signs of phlebitis, as they suggest decreased blood flow rather than inflammation. Drainage (choice D) may indicate an infection but is not specific to phlebitis. In summary, erythema is the key indicator of phlebitis due to the inflammatory response in the vein.