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A nurse is talking with an older adult client who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I'm not sure I want to retire.' Which of the following responses should the nurse make?
- A. You would have so much more time to spend with your family.'
- B. You should consider getting a part-time job or doing volunteer work.'
- C. Let's talk about how the change in your job status will affect you.'
- D. Why wouldn't you want to retire and relax?'
Correct Answer: C
Rationale: The correct response is C: "Let's talk about how the change in your job status will affect you." This response acknowledges the client's feelings and initiates a discussion about the potential impact of retirement on their well-being. It shows empathy and encourages open communication, allowing the nurse to explore the client's concerns and fears about retirement. This approach promotes client-centered care and helps the nurse understand the client's perspective better.
Choices A, B, and D are incorrect because they do not address the client's feelings or concerns directly. Option A assumes the client's main motivation for retirement is to spend time with family, which may not be the case. Option B and D provide suggestions without first understanding the client's thoughts and emotions, potentially dismissing their feelings. It is essential to prioritize the client's autonomy and individual needs in such discussions.
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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.
A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?
- A. Most people who have this procedure feel better following the treatment.'
- B. Your doctor wouldn't have ordered this treatment unless it was necessary.'
- C. It's okay to be nervous before this treatment.'
- D. You don't have to go through with the treatment.'
Correct Answer: D
Rationale: Correct Answer: D. "You don't have to go through with the treatment."
Rationale: This response respects the client's autonomy and right to make decisions about their own healthcare. It acknowledges the client's change of mind and supports their decision-making process without pressuring them. It is important for healthcare providers to prioritize patient autonomy and respect their choices.
Other Choices:
A: Incorrect. This statement may invalidate the client's feelings and pressure them to proceed with the treatment.
B: Incorrect. This statement undermines the client's autonomy by implying that the doctor's decision is more important than the client's own preferences.
C: Incorrect. While acknowledging nervousness is appropriate, it does not address the client's change of mind and decision to not proceed with the treatment.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
- A. Remove the cap and place it sterile-side up on a clean surface.
- B. Place sterile gauze over areas of spilled solution within the sterile field.
- C. Hold the bottle in the center of the sterile field when pouring the solution.
- D. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Correct Answer: A
Rationale: The correct answer is A because when setting up a sterile field, it is essential to maintain sterility. By removing the cap and placing it sterile-side up on a clean surface, the nurse ensures that the inside of the cap, which will come in contact with the solution, remains sterile. Placing the cap sterile-side up prevents contamination and maintains the integrity of the sterile field.
Choices B, C, and D are incorrect. Placing sterile gauze over spilled solution does not address the primary concern of maintaining sterility. Holding the bottle in the center of the sterile field or with the label facing away from the palm does not directly impact the sterility of the solution. Therefore, they are not the best actions to take when pouring the sterile solution during wound irrigation.
A nurse is caring for a client who has been admitted to the hospital. Select the 5 actions the nurse should take?
- A. Provide frequent rest periods for the client
- B. Restrict the client's sodium intake
- C. Advise the client to avoid the use of soap and alcohol-based lotions.
- D. Place the client on a low-carbohydrate diet
- E. Instruct the client to avoid blowing their nose forcefully
- F. Assess the client's level of orientation.
Correct Answer: A,B,C,E,F
Rationale: The correct actions for the nurse to take are A, B, C, E, and F. Providing rest periods (A) promotes healing and recovery. Restricting sodium intake (B) is important for certain conditions like hypertension. Advising the client to avoid soap and alcohol-based lotions (C) can prevent skin irritation. Instructing the client to avoid blowing their nose forcefully (E) prevents potential harm to nasal passages. Assessing the client's level of orientation (F) is crucial for monitoring mental status and detecting any changes. These actions prioritize the client's well-being, safety, and overall health.
A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?
- A. Remove the client's restraint every 4 hr.
- B. Document the client's condition every 15 min.
- C. Request a PRN restraint prescription for clients who are aggressive.
- D. Attach the restraint to the bed's side rail.
Correct Answer: B
Rationale: The correct answer is B: Document the client's condition every 15 min. This guideline is crucial to ensure the safety and well-being of the client in restraints. Documenting the client's condition frequently allows for timely identification of any signs of distress, discomfort, or complications related to the use of restraints. This practice helps in monitoring the client's physical and psychological status, enabling prompt intervention if necessary.
Removing the client's restraint every 4 hours (choice A) is incorrect as it may compromise the client's safety and increase the risk of injury or harm. Requesting a PRN restraint prescription for aggressive clients (choice C) is inappropriate as restraints should only be used as a last resort and not for convenience. Attaching the restraint to the bed's side rail (choice D) is unsafe and restricts the client's movement unnecessarily.