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A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?
- A. Wrap the blood pressure cuff snugly around the arm.
- B. Place the client's arm above the level of the heart.
- C. Check the instrument gauge to ensure the reading starts at zero.
- D. Center the cuff bladder over the brachial artery.
Correct Answer: B
Rationale: The correct answer is B because placing the client's arm above the level of the heart can result in an inaccurate blood pressure reading. Ideally, the arm should be at heart level to obtain an accurate measurement. A: Wrapping the cuff snugly ensures an accurate reading. C: Checking the gauge for zero ensures proper calibration. D: Centering the cuff bladder over the brachial artery is correct for accurate measurement. Overall, maintaining the arm at heart level is crucial to obtaining an accurate blood pressure reading.
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A nurse is preparing to insert an indwelling urinary catheter for a female client. After opening the catheter kit and preparing the supplies, which of the following steps should the nurse perform next?
- A. Cleanse the meatus.
- B. Don sterile gloves.
- C. Cleanse the labia.
- D. Lubricate the catheter.
Correct Answer: B
Rationale: The correct next step is to don sterile gloves (choice B). This is essential to maintain aseptic technique and prevent infection during catheter insertion. Sterile gloves create a barrier between the nurse's hands and the client's urinary tract, reducing the risk of introducing pathogens. Cleansing the meatus (choice A) or labia (choice C) should come after donning sterile gloves to prevent contamination. Lubricating the catheter (choice D) should be done just before insertion to facilitate a smooth and comfortable procedure.
A nurse is rehearsing assertive communication approaches to decline leadership of a nursing department committee. Which of the following statements by the nurse demonstrates assertiveness?
- A. You know this is not the right time for me to do this.
- B. Everyone knows there are others who can chair this committee better than I could.
- C. Can you tell me why you chose me?
- D. I decline the opportunity at this time.
Correct Answer: D
Rationale: Assertive communication is direct and respectful, clearly stating a decision without being passive or aggressive.
A client who is about to undergo hip arthroplasty tells the nurse she is afraid of not receiving adequate anesthesia during the procedure. Which of the following is an appropriate response?
- A. I will call the anesthesiologist right away.
- B. Can you tell me more about this concern?
- C. You have nothing to be concerned about. You have a competent anesthesiologist.
- D. I had a similar procedure and definitely received enough anesthesia.
Correct Answer: B
Rationale: Asking the client to elaborate allows for exploration of their concerns and reassurance through proper information.
A nurse at a community health clinic is assisting with creating a brochure about testicular cancer. Which of the following information should the nurse include?
- A. Perform a testicular self-examination twice per year.
- B. Palpate the epididymis.
- C. Gently roll the testicles to feel for abnormalities.
- D. Use one hand to palpate the testicles.
Correct Answer: C
Rationale: The correct answer is C: Gently roll the testicles to feel for abnormalities. This is the most appropriate information to include in the brochure because gently rolling the testicles between the thumb and fingers is the recommended technique for testicular self-examination. By rolling the testicles, individuals can better detect any lumps or changes in texture that may indicate testicular cancer.
Choice A is incorrect because the current recommendation is to perform testicular self-exams monthly, not twice per year. Choice B is incorrect as palpating the epididymis is not part of the standard testicular self-examination procedure. Choice D is incorrect because using both hands is recommended for better examination.
A nurse is reinforcing teaching with a newly licensed nurse about using the therapeutic technique of confrontation when caring for a client. Which of the following instructions should the nurse include in the teaching?
- A. Offer the client personal opinions.
- B. Change the subject when talking with the client.
- C. Use an aggressive tone of voice with the client.
- D. Establish a trusting relationship with the client.
Correct Answer: D
Rationale: Confrontation should be used in a therapeutic manner, requiring trust and sensitivity to help the client recognize inconsistencies in thoughts or behaviors.