Nokea
A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?
- A. Put on sterile gloves.
- B. Assist the client to the left Sims' position.
- C. Hang the enema container 61 cm (24 in) above the anus.
- D. Insert the tubing about 15 cm (6 in) into the anus.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to the left Sims' position. This position helps to facilitate the flow of the enema solution into the colon by allowing gravity to assist in the process. Placing the client in the left Sims' position helps to ensure proper administration and effectiveness of the enema.
A: Putting on sterile gloves is not necessary for administering a soapsuds enema.
C: Hanging the enema container 61 cm above the anus is not a standard practice for administering a soapsuds enema.
D: Inserting the tubing about 15 cm into the anus is too shallow and may not reach the desired area for the enema to be effective.
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A nurse is assisting in interviewing a client who is being admitted from a long-term care facility. In which of the following situations should the nurse ask a closed-ended question?
- A. Determining if the client is eating a well-balanced diet
- B. Asking the client about his receptiveness to the transfer
- C. Determining how the client completes his ADLs
- D. Asking if the client took his medications this morning
- E. *
Correct Answer: D
Rationale: Closed-ended questions are useful for obtaining specific, factual information, such as whether the client took their medications.
A nurse at a community-based health fair is promoting having a routine Papanicolaou test (Pap smear) to young adult women. Which of the following types of preventive care is the Pap smear?
- A. Primary level
- B. Secondary level
- C. Tertiary level
- D. Self-care ability level.
Correct Answer: B
Rationale: The correct answer is B: Secondary level preventive care. A Pap smear is a screening test that aims to detect precancerous or cancerous cells in the cervix at an early stage. This type of preventive care falls under secondary prevention because it focuses on early detection and treatment of disease before it progresses. Primary prevention (choice A) aims to prevent the disease from occurring in the first place. Tertiary prevention (choice C) focuses on managing and reducing the impact of the disease after it has already developed. Self-care ability level (choice D) is not a recognized level of preventive care.
While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?
- A. A systolic murmur
- B. A third heart sound (S3)
- C. An expected heart sound
- D. A fourth heart sound (S4)
Correct Answer: A
Rationale: The correct answer is A: A systolic murmur. Turbulence between S1 and S2 indicates a heart sound occurring during systole. Systolic murmurs are abnormal heart sounds heard between S1 and S2, often indicating a problem with the heart valves. S3 and S4 heart sounds occur after S2 and are associated with ventricular filling abnormalities. An expected heart sound would not exhibit turbulence. Therefore, the correct choice is A.
A nurse is preparing an in-service presentation about preventing health care-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?
- A. Chlorhexidine washes
- B. Urinary catheterization
- C. Malnutrition
- D. Multiple caregivers
Correct Answer: B
Rationale: The correct answer is B: Urinary catheterization. This is a common cause of HAIs due to the introduction of bacteria into the urinary tract. Catheters provide a direct pathway for bacteria to enter the body, leading to infections such as urinary tract infections. The other choices are incorrect because:
A: Chlorhexidine washes are actually used to prevent infections by killing bacteria on the skin.
C: Malnutrition can weaken the immune system and make individuals more susceptible to infections, but it is not a direct cause of HAIs.
D: Multiple caregivers can increase the risk of infections if proper hygiene practices are not followed, but it is not a specific cause of HAIs like urinary catheterization.
A nurse is reinforcing teaching with a newly licensed nurse about respecting a client's personal space. The nurse should include in the teaching that which of the following actions require client consent? (Select all that apply.)
- A. Removing the client's dentures
- B. Checking capillary refill of the client's finger
- C. Palpating for pedal edema
- D. Taking a radial pulse
- E. Observing a mole on the client's shoulder
Correct Answer: A, C
Rationale: Actions that involve physical touch or intrusion into personal space, such as removing dentures or palpating edema, require consent.