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A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take?
- A. Apply medicated powder under the vest to reduce itching
- B. Move the client up and down in bed by holding onto the halo traction device
- C. Ensure that there is space for one finger to fit between the vest and the client's skin
- D. Loosen or tighten the screws on the device as needed for the client's comfort
Correct Answer: C
Rationale: The correct answer is C: Ensure that there is space for one finger to fit between the vest and the client's skin. This is crucial to prevent pressure ulcers and skin breakdown. Tight fitting of the vest can lead to skin irritation and compromised circulation. A: Applying medicated powder can cause skin irritation and infection. B: Moving the client by holding onto the halo device can cause injury and dislodgement. D: Loosening or tightening screws without proper training can lead to complications.
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A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
- A. Ask a family member to be present during the admission.
- B. Request an interpreter during the initial assessment.
- C. Familiarize themselves with commonly used sign language.
- D. Obtain a board that uses colored pictures as communication.
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the most appropriate action as it ensures effective communication between the nurse and the client who uses sign language. It upholds the client's right to clear and accurate information regarding their care. Asking a family member (choice A) may not guarantee accurate communication and could breach confidentiality. Familiarizing oneself with sign language (choice C) takes time and may not be sufficient for complex medical discussions. Using a board with pictures (choice D) may not provide the client with the level of detail needed for comprehensive care. Overall, requesting an interpreter is the best choice for ensuring effective communication and respecting the client's rights.
A nurse is assessing a client who is postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. The client reports bladder spasms, and the nurse notes a scant amount of fluid in the urinary drainage bag, which of the following actions should the nurse take?
- A. Encourage the client to unseat every 2 hr
- B. Apply a cold compress to the suprapubic area
- C. Secure the urinary catheter to the upper left quadrant of the clients abdomen
- D. Use 0.9% sodium chloride to perform an intermittent bladder irrigation
Correct Answer: D
Rationale: The correct answer is D: Use 0.9% sodium chloride to perform an intermittent bladder irrigation. In this scenario, the client is experiencing bladder spasms and a scant amount of fluid in the drainage bag, indicating a potential blockage or clot in the catheter. Performing an intermittent bladder irrigation with 0.9% sodium chloride can help to clear the catheter and improve urine flow. This intervention helps prevent further complications such as urinary retention or infection. Encouraging the client to unseat or applying a cold compress may not address the underlying issue of catheter blockage. Securing the catheter to the upper left quadrant does not directly address the current problem and may not improve urine flow.
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?
- A. Weight gain
- B. Distended abdomen
- C. Confusion
- D. Dyspnea
Correct Answer: D
Rationale: The correct answer is D: Dyspnea. In left-sided heart failure, the heart is unable to pump efficiently, leading to a decrease in cardiac output. Dyspnea (shortness of breath) occurs due to the accumulation of fluid in the lungs (pulmonary congestion), indicating decreased cardiac output. Weight gain (A) and distended abdomen (B) are more indicative of right-sided heart failure. Confusion (C) can be a sign of decreased cerebral perfusion, but dyspnea is a more direct indicator of decreased cardiac output in left-sided heart failure.
A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?
- A. I can arrange for a social worker to talk to you before you leave.
- B. I can contact the occupational therapist to schedule a home visit.
- C. Contact your pharmacy to inquire about a different medication.
- D. You should ask your provider to prescribe a cheaper medication.
Correct Answer: A
Rationale: The correct answer is A because the nurse should address the client's financial concerns by offering a social worker to assist with resources. This option demonstrates holistic care and supports the client's well-being beyond the medical aspect. Option B is irrelevant as it does not address the medication affordability issue. Option C puts the burden on the client to find a solution. Option D is not appropriate as the client may not feel comfortable asking for a cheaper medication directly.
A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?
- A. Make sure the client's room has positive pressure airflow.
- B. Make sure dietary plates and utensils are disposable.
- C. Wear an N95 respirator when providing direct client care.
- D. Monitor the client's temperature once every 6 hr.
Correct Answer: A
Rationale: Correct Answer: A: Make sure the client's room has positive pressure airflow.
Rationale:
1. Positive pressure airflow prevents contaminated air from entering the room, reducing the risk of infections.
2. It helps maintain a clean environment by keeping airborne pathogens out.
3. Protects the client who has a compromised immune system post-transplant.
Summary of Incorrect Choices:
B: Disposable utensils are important but do not directly protect the client from airborne infections.
C: N95 respirators are for the healthcare provider's protection, not the client's.
D: Monitoring temperature is essential but does not directly prevent infections in a protective isolation setting.