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A nurse is planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hr ago. Which of the following actions should the nurse include in the plan?
- A. Encourage the client to apply a heating pad for 2 hr at a time.
- B. Instruct the client to take deep, rhythmic breaths.
- C. Apply an ice pack to the client's back for 1 hr.
- D. Remove distractions from the client's room.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to take deep, rhythmic breaths. Deep breathing helps promote relaxation, reduces muscle tension, and distracts the client from pain sensations. This can be an effective nonpharmacological pain relief method.
A: Encouraging the client to apply a heating pad for 2 hours at a time may exacerbate the pain if it's already mild.
C: Applying an ice pack for 1 hour may not be suitable for mild back pain as it is more effective for acute injuries.
D: Removing distractions may help, but it does not directly address the client's pain.
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A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include?
- A. Change the dressing four times per day.
- B. Apply tincture of benzoin prior to removing the dressing.
- C. Use sterile gloves when removing the old dressing.
- D. Clean from the incision to the surrounding skin.
Correct Answer: C
Rationale: The correct answer is C: Use sterile gloves when removing the old dressing. This is important to prevent introducing infection to the incision site. Sterile gloves help maintain asepsis during the dressing change, reducing the risk of contamination. Changing the dressing four times per day (A) may disrupt the wound healing process by removing necessary protective barriers. Applying tincture of benzoin (B) can cause skin irritation and is unnecessary for routine dressing changes. Cleaning from the incision to the surrounding skin (D) can introduce microorganisms from the surrounding skin to the incision site, increasing infection risk.
A nurse is caring for a client who has a traumatic brain injury and needs to relearn how to use eating utensils. The nurse should refer the client to which of the following members of the interprofessional team?
- A. Physical therapist
- B. Speech-language pathologist
- C. Occupational therapist
- D. Social worker
Correct Answer: C
Rationale: The correct answer is C: Occupational therapist. Occupational therapists specialize in helping individuals regain skills needed for daily activities, such as using eating utensils. They focus on enhancing fine motor skills and cognitive abilities necessary for independent living. Referring the client to an occupational therapist will ensure a comprehensive approach to relearning utensil use. Physical therapists (A) focus on mobility and strength, not fine motor skills. Speech-language pathologists (B) address communication and swallowing issues, not utensil use. Social workers (D) assist with psychosocial support, not utensil retraining.
A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse's signature on the form confirms which of the following requirements? (Select all that apply.)
- A. The client speaks the same language as the nurse.
- B. The client has legal authority to do so.
- C. The client does not have a mental health condition.
- D. The client signed in the nurse's presence.
- E. The client was not coerced.
Correct Answer: B,D,E
Rationale: The correct answers are B, D, and E. B is essential as the client must have legal authority to give informed consent. D is crucial as the client's signature in the nurse's presence ensures authenticity. E is important to confirm that the client was not coerced. Choice A is incorrect as language proficiency does not determine consent validity. Choice C is incorrect as having a mental health condition does not automatically invalidate consent.
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
- A. The client drinks their thickened juice with a straw.
- B. The client adjusts the head of their bed to 90°.
- C. The client tucks their chin when they swallow.
- D. The client takes frequent breaks while eating.
Correct Answer: A
Rationale: Correct Answer: A. The client drinking thickened juice with a straw indicates a potential aspiration risk. Straws can bypass the oral phase of swallowing, increasing the likelihood of aspiration. Thickened liquids are meant to slow down the flow of fluids to prevent choking or aspiration. Therefore, the nurse should intervene to prevent potential harm to the client.
Incorrect Choices:
B: Adjusting the head of the bed to 90° is the correct positioning to prevent aspiration during swallowing.
C: Tucking the chin when swallowing helps to protect the airway and prevent aspiration.
D: Taking frequent breaks while eating is a good strategy for clients with dysphagia to prevent fatigue and reduce the risk of aspiration.
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
- A. Change the PN infusion bag every 48 hr.
- B. Obtain a random blood glucose daily.
- C. Prepare the client for a central venous line.
- D. Administer the PN and fat emulsion separately.
Correct Answer: C
Rationale: The correct answer is C: Prepare the client for a central venous line. Parenteral nutrition (PN) with high dextrose concentrations can cause phlebitis and tissue damage if administered through a peripheral IV line. Therefore, a central venous line is appropriate for administering PN to prevent complications. Changing the PN bag every 48 hours (A) is important for infection control but not directly related to the administration method. Obtaining a random blood glucose daily (B) is important for monitoring glucose levels but does not address the administration method. Administering the PN and fat emulsion separately (D) is not necessary as they can be mixed in the same solution.