Nokea
A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, 'You are not putting that hose down my throat.' Which of the following statements should the nurse make?
- A. 'I can see that this is upsetting you.'
- B. 'It is necessary for your treatment.'
- C. 'It will be over quickly, and you will feel better.'
- D. 'Let me explain again why this procedure is important.'
Correct Answer: A
Rationale: In this situation, the nurse should acknowledge the client's feelings by stating, 'I can see that this is upsetting you.' This response validates the client's emotions and demonstrates empathy, which can help build trust and rapport. Choice B is too direct and might not address the client's emotional state. Choice C focuses on the outcome rather than the client's current distress. Choice D does not directly address the client's feelings of distress and may not effectively alleviate their anxiety.
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The healthcare provider attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?
- A. BP 142/88 mmHg
- B. 2+ edema of fingers and hands
- C. Radial pulse volume is +3
- D. Capillary refill time is 2 seconds
Correct Answer: B
Rationale: Edema, indicated by 2+ edema of fingers and hands, can impair blood flow and peripheral perfusion, leading to reduced oxygen saturation readings on a pulse oximeter. High blood pressure (choice A) would not directly affect oxygen saturation readings. Radial pulse volume (choice C) and capillary refill time (choice D) are more related to assessing circulation rather than contributing significantly to oxygen saturation readings.
A patient is placed in the Sims' position. Which areas will the nurse observe for pressure points?
- A. Chin, elbow, hips
- B. Ileum, clavicle, humerus
- C. Shoulder, anterior iliac spine, ankles
- D. Occipital region of the head, coccyx, heels
Correct Answer: B
Rationale: When a patient is placed in the Sims' position, the nurse should observe pressure points on the ileum, clavicle, humerus, knees, and ankles. Choice A is incorrect as the chin and hips are not typically pressure points in the Sims' position. Choice C is incorrect as the shoulder and anterior iliac spine are not commonly observed pressure points in this position. Choice D is also incorrect as the occipital region of the head, coccyx, and heels are not pressure points commonly associated with the Sims' position.
During an initial history and physical assessment of a 3-month-old brought into the clinic for spitting up and excessive gas, what would the nurse expect to find?
- A. Increased temperature and lethargy
- B. Restlessness and increased mucus production
- C. Increased sleeping and listlessness
- D. Diarrhea and poor skin turgor
Correct Answer: B
Rationale: Restlessness and increased mucus production are common signs of gastrointestinal issues or reflux in infants, which could explain the symptoms of spitting up and excessive gas. Increased temperature and lethargy (Choice A) are more indicative of an infection rather than gastrointestinal issues. Increased sleeping and listlessness (Choice C) are not typical signs associated with the symptoms described. Diarrhea and poor skin turgor (Choice D) are not directly related to the symptoms of spitting up and gas in this scenario.
When should discharge planning be initiated for a client experiencing an exacerbation of heart failure?
- A. During the admission process.
- B. After the client stabilizes.
- C. Only after the client requests it.
- D. At the time of discharge.
Correct Answer: A
Rationale: Discharge planning should begin during the admission process for a client experiencing an exacerbation of heart failure. Initiating discharge planning early ensures timely and effective care transitions, which are crucial for managing the client's condition and preventing readmissions. Waiting until after the client stabilizes (choice B) could lead to delays in arranging necessary follow-up care and support services. Similarly, waiting for the client to request discharge planning (choice C) may result in missed opportunities for comprehensive care coordination. Planning at the time of discharge (choice D) is too late, as early intervention is key to promoting the client's well-being and recovery in the long term.
A healthcare professional is admitting a client who has influenza. Which of the following types of transmission precautions should the healthcare professional initiate?
- A. Airborne
- B. Droplet
- C. Contact
- D. Protective environment
Correct Answer: B
Rationale: Droplet precautions should be initiated for clients with infections that spread via droplet nuclei larger than 5 microns in diameter, such as influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. In the case of influenza, the virus is primarily spread through respiratory droplets produced when an infected person coughs, sneezes, or talks. Airborne precautions are used for pathogens that remain infectious over long distances, typically smaller than 5 microns, like tuberculosis. Contact precautions are for diseases transmitted by direct or indirect contact, and protective environment precautions are for immunocompromised individuals to protect them from environmental pathogens.