Nokea
A nurse is planning care for a client who is 1 day postoperative following spinal fusion. Which of the following actions should the nurse include?
- A. Assist the client to sit upright in a chair for 4 hours at a time.
- B. Expect clear drainage on the spinal dressing.
- C. Log roll the client every 2 hours.
- D. Perform neurological checks every 8 hours.
Correct Answer: C
Rationale: The correct answer is C: Log roll the client every 2 hours. This action is crucial for preventing complications such as pressure ulcers and maintaining spinal alignment post spinal fusion surgery. Log rolling helps to keep the spine in proper alignment and reduces the risk of injury to the surgical site. Assisting the client to sit upright for 4 hours at a time (choice A) can put excessive pressure on the surgical site and hinder the healing process. Expecting clear drainage on the spinal dressing (choice B) is not appropriate as drainage may vary and is not necessarily an indicator of infection. Performing neurological checks every 8 hours (choice D) is important but should be done more frequently in the immediate postoperative period.
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A nurse is caring for a client who has delusional behavior and states, 'I can’t go to group therapy today. I am expecting a high-level official to visit me.' The nurse responds, 'I understand, but it is time for group therapy and we expect everyone to attend. Let’s walk over together.' For which of the following reasons is the nurse’s response considered therapeutic?
- A. It clearly articulates the expectations of the client.
- B. It demonstrates empathy towards the client.
- C. It sets limits on the client’s manipulative behavior.
- D. It uses reflection when talking with the client.
Correct Answer: B
Rationale: The correct answer is B: It demonstrates empathy towards the client. By acknowledging the client's feelings and showing understanding, the nurse is building a therapeutic relationship based on empathy. This approach helps the client feel heard and validated, fostering trust and cooperation. The other choices are incorrect because: A) while the response does articulate expectations, it does not address the client's emotions or perspective; C) while setting limits is important, the response does not directly address manipulative behavior; D) reflection involves paraphrasing or summarizing the client's thoughts, which is not evident in the nurse's response.
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for?
- A. Hemorrhage
- B. Infection
- C. Urinary retention
- D. Pain
Correct Answer: A
Rationale: The correct answer is A: Hemorrhage. Postoperative hemorrhage is a critical complication following a transurethral resection of the prostate due to the rich blood supply in the area. It can lead to hypovolemic shock and requires immediate intervention to prevent further complications. Monitoring for signs of bleeding such as increased heart rate, decreased blood pressure, and decreased urine output is crucial.
B: Infection is an important complication to monitor for but is not as immediately life-threatening as hemorrhage.
C: Urinary retention can occur postoperatively but is not as urgent as hemorrhage.
D: Pain management is important for the client's comfort, but it is not the priority in this situation.
In summary, monitoring for hemorrhage is crucial as it is the most life-threatening complication that requires immediate attention compared to the other options.
A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times?
- A. 730
- B. 745
- C. 815
- D. 720
Correct Answer: A
Rationale: The correct answer is A: 730. After administering regular insulin, it is crucial to ensure the client receives breakfast within 30 minutes to an hour to prevent hypoglycemia. Breakfast at 730 allows adequate time for the insulin to start working before the client consumes food. Choice B (745) is too late, increasing the risk of hypoglycemia. Choice C (815) is too delayed and may cause an imbalance in blood sugar levels. Choice D (720) is too soon after administering insulin, increasing the risk of hypoglycemia.
A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.2
Rationale: The correct answer is 0.2 mL. To calculate this, divide the desired dose (2 mg) by the concentration (10 mg/mL). This gives 0.2 mL. The other choices are incorrect because: A) 2 mL would be an overdose; B) 0.02 mL is too small a dose; C) 20 mL is an overdose; D) 0.02 mL is too small a dose; E) 0.02 mL is too small a dose; F) 20 mL is an overdose; G) 2 mL would be an overdose.
A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the student indicates understanding of the discussion?
- A. This stage is when testing occurs to identify boundaries of interpersonal behaviors.
- B. Consensus evolves in this stage.
- C. This stage involves constructive efforts on the part of the group members.
- D. Resistance is evident as subgroups form in this stage.
Correct Answer: B
Rationale: The correct answer is B: Consensus evolves in this stage. During the norming stage of group development, members begin to resolve conflicts and establish norms and values. Consensus-building is crucial in this stage to ensure everyone is on the same page and working towards common goals. This process helps the group to develop cohesion and unity.
Choice A is incorrect because testing occurs in the forming stage, not norming. Choice C is incorrect because constructive efforts typically occur in the performing stage, not norming. Choice D is incorrect because resistance and subgroup formation usually happen in the storming stage, not norming.