Nokea
A nurse is supervising a newly licensed nurse who is female while she performs postmortem care on a male client who is Muslim. Which of the following actions by the newly licensed nurse should prompt the nurse to intervene?
- A. Leaves the client's dentures in his mouth
- B. Prepares to cleanse the client's body
- C. Disconnects the cardiac monitor from the client
- D. Removes soiled linens from the client
Correct Answer: B
Rationale: In Islamic practices, same-gender family members or religious personnel should perform body cleansing. A female nurse cleansing a male client would require intervention.
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A nurse is caring for a client who says, 'I'm feeling a bit nervous today.' Which of the following responses should the nurse make?
- A. Please explain what you mean by nervous.
- B. Why are you nervous?
- C. Would a backrub ease your nervousness?
- D. You look like you feel nervous.
Correct Answer: A
Rationale: Seeking clarification helps the nurse understand the client's feelings more accurately.
A nurse in a long-term care facility sees a client who is choking. Which of the following data should the nurse identify as requiring an abdominal thrust?
- A. The client is grasping his abdomen
- B. The client is hyperventilating
- C. The client is coughing
- D. The client cannot speak
Correct Answer: D
Rationale: Inability to speak is a sign of complete airway obstruction requiring abdominal thrusts. Coughing indicates partial obstruction and does not require immediate thrusts.
A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements should the nurse identify as an indication that the client understands and accepts his prognosis?
- A. I am thinking of getting a second opinion.
- B. I am hoping this will help relieve my discomfort.
- C. This is making me stronger every day.
- D. This is not working, and I plan to stop treatment.
Correct Answer: B
Rationale: Palliative care focuses on symptom relief, and the statement reflects an understanding of this goal.
A nurse is caring for an older adult client who is Chinese and is recovering from a bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which of the following purposes?
- A. To regulate blood pressure
- B. To promote digestion
- C. To enhance the immune system
- D. To reduce inflammation
Correct Answer: B
Rationale: The correct answer is B: To promote digestion. Ginger tea is commonly used in Chinese culture to aid digestion and alleviate gastrointestinal issues, making it a suitable choice for a client recovering from a bowel obstruction. Ginger has natural properties that can help stimulate digestive enzymes and improve digestion. This can be beneficial for the client to ease any potential digestive discomfort after the bowel obstruction.
Other choices are incorrect because:
A: Ginger tea is not typically used to regulate blood pressure.
C: While ginger can have some immune-boosting properties, the primary purpose in this scenario is related to digestion.
D: Ginger does have anti-inflammatory properties, but the client's request for ginger tea is more likely for digestive purposes.
A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
- A. Count the apical pulsations for a full minute.
- B. Check the apical pulse with a Doppler device.
- C. Use the diaphragm of the stethoscope to listen to the apical pulsations.
- D. Press the stethoscope firmly against the client's skin.
Correct Answer: A
Rationale: The correct answer is A: Count the apical pulsations for a full minute. This is because counting the apical pulse for a full minute provides the most accurate and reliable measurement of the heart rate, especially in clients taking cardiovascular medications where variations may occur. Checking for a full minute allows the nurse to capture any irregularities or changes in the pulse rhythm.
Choice B is incorrect because using a Doppler device is not necessary for routine assessment of the apical pulse. Choice C is incorrect as the bell of the stethoscope, not the diaphragm, is used to listen to the apical pulse for better sound transmission. Choice D is incorrect as pressing the stethoscope firmly against the skin can distort the sound of the pulse.