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A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching?
- A. Apply petroleum jelly to soothe the mucous membranes.
- B. Use synthetic fabrics for the client's bedding.
- C. Clean the equipment with an alcohol-based cleaning product.
- D. Avoid using nail polish remover around the client.
Correct Answer: D
Rationale: The correct answer is D: Avoid using nail polish remover around the client. Nail polish remover contains acetone, which is highly flammable and can pose a serious risk when in contact with oxygen therapy equipment. It is crucial to prevent any potential sources of ignition near oxygen therapy to ensure the safety of the client.
Incorrect choices:
A: Apply petroleum jelly to soothe the mucous membranes - Petroleum jelly is flammable and should not be used near oxygen therapy.
B: Use synthetic fabrics for the client's bedding - The type of bedding material is not directly related to home oxygen therapy.
C: Clean the equipment with an alcohol-based cleaning product - Alcohol-based products are flammable and should be avoided around oxygen therapy equipment.
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A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
- A. Check the client for injuries.
- B. Move hazardous objects away from the client.
- C. Notify the provider.
- D. Ask the client to describe how she felt prior to the fall.
Correct Answer: A
Rationale: The correct action is to check the client for injuries first because ensuring the client's immediate safety and well-being is the top priority. By assessing for injuries, the nurse can determine the severity of the situation and provide necessary interventions promptly. Moving hazardous objects (B) can wait until after ensuring the client's safety. Notifying the provider (C) can also be done after assessing the client's condition. Asking the client to describe how she felt prior to the fall (D) is important for gathering information but is not as urgent as checking for injuries.
A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?
- A. Suggest rinsing his mouth with an alcohol-based mouthwash
- B. Provide humidification of the room air
- C. Offer the client saltine crackers between meals
- D. Instruct the client on the use of esophageal speech
Correct Answer: B
Rationale: The correct answer is B: Provide humidification of the room air. Xerostomia is dry mouth often caused by radiation therapy, which can lead to discomfort and difficulty swallowing. Humidifying the room air can help alleviate dryness, making it easier for the client to breathe and swallow. Alcohol-based mouthwash (A) can worsen dryness due to its drying effect. Saltine crackers (C) can be difficult to swallow with a dry mouth. Esophageal speech (D) is not relevant to xerostomia.
A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take?
- A. The nurse should use a filter needle to withdraw the medication.
- B. The nurse should break the neck of the ampule toward their body.
- C. The nurse should use the same needle to draw up and inject the client.
- D. The nurse should dispose of the ampule in the trash can.
Correct Answer: A
Rationale: The correct answer is A. Using a filter needle to withdraw the medication from a glass ampule helps prevent glass particles from contaminating the medication. Breaking the neck of the ampule toward the body (choice B) can lead to injury. Using the same needle to draw up and inject the client (choice C) increases the risk of contamination. Disposing of the ampule in the trash can (choice D) without following proper disposal protocols can be hazardous.
A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?
- A. Fidelity
- B. Veracity
- C. Autonomy
- D. Beneficence
Correct Answer: D
Rationale: The correct answer is D: Beneficence. Beneficence is the ethical principle of doing good or promoting the well-being of others. By sitting with the client to provide comfort after the loss of their partner, the nurse is demonstrating beneficence by actively seeking to alleviate the client's suffering and promoting their emotional well-being.
Rationale for why the other choices are incorrect:
A: Fidelity relates to the nurse's obligation to be faithful and keep promises made to the client, which is not directly demonstrated in this scenario.
B: Veracity is the principle of truthfulness, which is not the primary focus of the nurse's actions in this situation.
C: Autonomy refers to respecting the client's right to make their own decisions, which is not the main principle being demonstrated when the nurse is providing comfort and support.
E, F, G: These choices are not provided, but based on the context of the scenario, they are not relevant to the nurse's actions in providing comfort
A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?
- A. Examine for leakage at the site of the procedure.
- B. Compare the client's current weight with preprocedure weight.
- C. Confirm that the client is able to urinate.
- D. Check the client's serum albumin levels.
Correct Answer: B
Rationale: The correct answer is B: Compare the client's current weight with preprocedure weight. This is because paracentesis is a procedure used to remove fluid buildup in the abdomen, which can lead to weight loss. By comparing the client's current weight with the preprocedure weight, the nurse can evaluate the effectiveness of the procedure in draining the excess fluid. This comparison helps determine the amount of fluid removed and assess the client's response to the treatment.
Explanations for why the other choices are incorrect:
A: Examining for leakage at the site of the procedure is important for monitoring for potential complications but does not directly evaluate the effectiveness of the procedure.
C: Confirming that the client is able to urinate is important for assessing kidney function but does not specifically evaluate the effectiveness of the paracentesis.
D: Checking the client's serum albumin levels may provide information about the client's liver function and nutritional status but does not directly evaluate the effectiveness of the paracentesis procedure.