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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 answer is A: Check the client for injuries. This should be the first action taken because the nurse needs to assess the client's immediate physical condition to determine if there are any life-threatening injuries that require immediate attention. 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 about how she felt prior to the fall (D) is important but not as urgent as checking for injuries.
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A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?
- A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client.
- B. Determine the reasons why the client is refusing to use the incentive spirometer.
- C. Document the client's refusal to participate in health restorative activities.
- D. Administer a pain medication to the client.
Correct Answer: B
Rationale: The correct answer is B: Determine the reasons why the client is refusing to use the incentive spirometer. The priority is to assess the client's reasons for refusal to address any barriers preventing compliance, such as fear, pain, or lack of understanding. Understanding the client's perspective can help tailor interventions and address concerns effectively. Requesting a respiratory therapist (choice A) or administering pain medication (choice D) can be secondary once the client's reasons are identified. Simply documenting the refusal (choice C) without addressing the underlying cause does not promote client-centered care.
A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?
- A. An angiocatheter
- B. A 25-gauge needle
- C. A butterfly needle
- D. A non-coring needle
Correct Answer: D
Rationale: The correct answer is D: A non-coring needle. This type of needle is specifically designed for accessing implanted venous access ports as it minimizes the risk of coring (removal of a piece of the septum) which can lead to complications. Using an angiocatheter (choice A) or a butterfly needle (choice C) can increase the risk of coring, causing damage to the port. A 25-gauge needle (choice B) is too small for accessing the port effectively. In summary, the non-coring needle is the optimal choice for accessing the port safely and effectively, while the other options pose risks of coring or inefficiency.
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 creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan?
- A. Wear loose-fitting underwear.
- B. Take a bubble bath after intercourse.
- C. Drink four 240 mL (8 oz) glasses of water each day.
- D. Void every 5 to 6 hr during the day.
Correct Answer: A
Rationale: Correct Answer: A: Wear loose-fitting underwear.
Rationale:
1. Loose-fitting underwear allows for better air circulation, reducing moisture and bacterial growth.
2. Tight clothing can create a warm, moist environment ideal for bacterial growth.
3. Preventing moisture buildup can help reduce the risk of urinary tract infections.
Summary of other choices:
B: Taking a bubble bath after intercourse can introduce bacteria into the urinary tract, increasing the risk of infection.
C: Drinking water is important for overall health but does not directly prevent urinary tract infections.
D: Voiding every 5 to 6 hours is a good practice, but it does not directly address the prevention of urinary tract infections.
A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify her religious preferences?
- A. Do you receive Holy Communion?
- B. Do you follow a kosher diet?
- C. Do you consume pork products?
- D. Do you oppose receiving a blood transfusion if necessary?
Correct Answer: C
Rationale: The correct answer is C: Do you consume pork products? This question is relevant for a client practicing Islam as pork consumption is prohibited in Islam. Asking about pork consumption helps the nurse understand and respect the client's religious beliefs.
Incorrect answers:
A: Do you receive Holy Communion? - This question is related to Christian practices, not Islam.
B: Do you follow a kosher diet? - This question is related to Jewish dietary laws, not specific to Islam.
D: Do you oppose receiving a blood transfusion if necessary? - While some religious beliefs may affect views on blood transfusions, this question does not specifically address Islamic beliefs.