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A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?
- A. Evaluate electrolytes
- B. Restrict fluid intake
- C. Administer diuretics
- D. Monitor vital signs
Correct Answer: A
Rationale: When a client has fluid overload, the nurse's first action should be to evaluate electrolytes. Electrolyte levels can be significantly affected by fluid imbalances, and assessing them will guide the nurse in determining the appropriate interventions. Restricting fluid intake (choice B) may be necessary but is not the initial priority. Administering diuretics (choice C) should be based on the electrolyte evaluation and overall assessment. Monitoring vital signs (choice D) is essential but does not provide direct information on the client's electrolyte status, which is crucial in managing fluid overload.
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A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?
- A. "It might help me to listen to music while I'm lying in bed."
- B. "I will use the pain medication as prescribed to manage the pain."
- C. "I will request a different type of pain medication if the pain persists."
- D. "I will ask for a physical therapist to help with the pain."
Correct Answer: A
Rationale: The correct answer is A. Listening to music is a non-pharmacological method to help manage mild pain, reflecting an understanding of pain management strategies. It shows the client's grasp of non-pharmacological pain management techniques taught preoperatively. Choice B, while important, only addresses pharmacological pain management, omitting other strategies discussed in preoperative teaching. Choice C jumps to changing medications without considering non-pharmacological methods first, indicating a narrow approach to pain management. Choice D involves a physical therapist, which is not directly related to the pain management strategies typically discussed in preoperative teaching.
A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further?
- A. "I am struggling to accept that my parents are aging and need so much help."
- B. "It's been so stressful for me to think about having intimate relationships."
- C. "I know I should volunteer my time for a good cause, but maybe I'm just selfish."
- D. "I love my grandchildren, but my child expects me to relive my parenting days."
Correct Answer: A
Rationale: The correct answer is A. The statement about struggling with aging parents indicates a significant stressor that could impact overall well-being and warrants further assessment. This statement reveals a potential source of emotional distress and adjustment difficulties for the client, as aging parents needing help can be a complex issue involving feelings of loss, role reversal, and increased responsibilities. Choices B, C, and D, although important, do not signify as immediate a need for further assessment compared to the challenges related to aging parents. Choice B focuses on intimate relationships, which is a common concern but may not be as urgent as dealing with aging parents. Choice C reflects feelings of selfishness but does not indicate an immediate need for further assessment. Choice D involves expectations from the client's child but does not highlight a critical issue that could impact the client's well-being as directly as struggling with aging parents.
A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain medication is not an option for managing pain. Which of the following is an appropriate response by the nurse?
- A. I'm sure it will work if you just give it a chance.
- B. You may take any herbal remedies you bring from home.
- C. Why do you think pain medication is not going to help you?
- D. Would you like me to give you a back massage?
Correct Answer: D
Rationale: In this scenario, the client has expressed that pain medication is not an option for managing pain. Offering alternative pain relief options like a back massage is appropriate because it respects the client's preferences and provides a non-pharmacological intervention to help alleviate pain. Choices A, B, and C are not as suitable: A may come across as dismissive of the client's decision, B may not be safe as herbal remedies can interact with medical treatments, and C focuses more on questioning the client's decision rather than providing immediate comfort.
A client who has just had a mastectomy has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device?
- A. Collapsing the device whenever it is 1/2 to 2/3 full of air.
- B. Emptying the device every 4 hours.
- C. Replacing the device every 24 hours.
- D. Keeping the device above the level of the surgical site.
Correct Answer: A
Rationale: Collapsing the device when it is 1/2 to 2/3 full of air is the correct nursing action to ensure proper operation of a closed wound suction device (hemovac). This action maintains negative pressure, which is essential for proper suction and drainage of the wound. Emptying the device every 4 hours (Choice B) is not necessary as the focus should be on collapsing it appropriately. Replacing the device every 24 hours (Choice C) is not a standard practice unless indicated by the healthcare provider. Keeping the device above the level of the surgical site (Choice D) is not necessary for the device's proper operation; collapsing it to maintain negative pressure is the key action.
The LPN/LVN is assisting with the care of a client who has had a stroke. Which intervention is most important to include in the client's plan of care to prevent joint contractures?
- A. Encourage the client to perform active range-of-motion exercises.
- B. Use pillows to keep the client's extremities in a functional position.
- C. Place the client in a prone position for 30 minutes each day.
- D. Perform passive range-of-motion exercises on the affected side.
Correct Answer: B
Rationale: Using pillows to keep the client's extremities in a functional position is crucial in preventing joint contractures. This intervention helps maintain proper alignment of the joints and reduces the risk of contractures by preventing prolonged positioning that can lead to muscle shortening. Encouraging the client to perform active range-of-motion exercises (Choice A) is beneficial for maintaining mobility but may not be the most important intervention to prevent joint contractures. Placing the client in a prone position for 30 minutes each day (Choice C) can be helpful for preventing pressure ulcers but is not directly related to preventing joint contractures. Performing passive range-of-motion exercises on the affected side (Choice D) can aid in maintaining joint flexibility but may not be as crucial as using pillows to prevent joint contractures.