Nokea
A nurse is teaching a client with type 2 diabetes about the importance of foot care. Which statement by the client indicates a need for further teaching?
- A. I should check my feet every day for cuts or blisters.
- B. I need to moisturize my feet daily, especially between my toes.
- C. I should wear comfortable shoes that fit well.
- D. I should avoid walking barefoot, even indoors.
Correct Answer: B
Rationale: The correct answer is B. Moisturizing between the toes can create a moist environment that fosters fungal infections. Checking the feet daily for cuts or blisters (choice A) is correct in diabetes management to prevent complications. Wearing comfortable shoes that fit well (choice C) and avoiding walking barefoot (choice D) are also essential in preventing foot ulcers and injuries in diabetic patients.
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In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?
- A. An older client who fell yesterday and is now complaining of diplopia.
- B. An adult newly diagnosed with type 1 diabetes and high cholesterol.
- C. A client with pancreatic cancer who is experiencing intractable pain.
- D. An older client post-stroke who is aphasic with right-sided hemiplegia.
Correct Answer: D
Rationale: The best client for the charge nurse to assign to a practical nurse (PN) is an older client post-stroke who is aphasic with right-sided hemiplegia. This client is stable and suitable for care by a PN under supervision. Choices A, B, and C present clients with more complex and acute conditions that would require a higher level of nursing expertise and intervention.
A client with a tracheostomy is experiencing thick, tenacious secretions. Which intervention should the nurse implement first?
- A. Encourage fluid intake to thin secretions.
- B. Administer a mucolytic agent.
- C. Increase humidity in the client's room.
- D. Perform deep suctioning as needed.
Correct Answer: C
Rationale: Increasing humidity in the client's room is the initial intervention for managing thick, tenacious secretions in a client with a tracheostomy. Adequate humidity helps to hydrate secretions, making them easier to clear, thus improving airway clearance. Encouraging fluid intake (Choice A) can be beneficial but is not the first-line intervention. Administering a mucolytic agent (Choice B) may be considered if increasing humidity alone is insufficient. Performing deep suctioning (Choice D) should be reserved for when other measures like increasing humidity have been ineffective.
A client with newly diagnosed hypertension is being taught about lifestyle modifications by a nurse. Which client statement indicates a need for further teaching?
- A. 'I will reduce my salt intake to help manage my blood pressure.'
- B. 'I will start exercising regularly to help control my blood pressure.'
- C. 'I will avoid drinking alcohol to help manage my blood pressure.'
- D. 'I will limit my caffeine intake to help control my blood pressure.'
Correct Answer: D
Rationale: The correct answer is D. Limiting caffeine intake is a positive lifestyle modification for managing hypertension. The statement indicates that the client understands the importance of reducing caffeine intake. Choices A, B, and C all reflect appropriate lifestyle modifications for managing hypertension, indicating good understanding by the client.
The nurse is preparing to administer an enema to a client with severe constipation. Which position is most appropriate for the client?
- A. Supine with the head elevated 30 degrees
- B. Left lateral with the right leg flexed
- C. Sims' position with the right leg flexed
- D. Prone position with the head turned to the side
Correct Answer: C
Rationale: Sims' position with the right leg flexed is the most appropriate position for administering an enema to a client with severe constipation. This position helps in promoting the flow of the enema solution into the rectum and facilitates the evacuation of stool. Supine position with the head elevated 30 degrees (Choice A) is not ideal for administering an enema as it does not facilitate the flow of the solution. Left lateral position with the right leg flexed (Choice B) is not the best choice for administering an enema. Prone position with the head turned to the side (Choice D) is also not suitable for administering an enema as it does not assist in the proper administration and retention of the solution.
The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent, and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and the interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, 'She says it is OK.' What action should the nurse take next?
- A. Ask for a full explanation from the interpreter of the witnessed discussion.
- B. Have the client sign the consent form.
- C. Document the conversation and witness the consent.
- D. Ask the client directly if she has any questions.
Correct Answer: A
Rationale: The correct action for the nurse to take next is to ask for a full explanation from the interpreter of the witnessed discussion. Verbal consent is not sufficient; it is crucial to ensure that the client fully comprehends the risks and benefits of the surgical procedure. By asking the interpreter to provide a detailed explanation of the discussion, the nurse can confirm that the client has given informed consent. Having the client sign the consent form (Choice B) without ensuring complete understanding may lead to potential misunderstandings. Documenting the conversation and witnessing the consent (Choice C) is not enough to guarantee the client's comprehension. Asking the client directly if she has any questions (Choice D) may not be effective if language barriers persist.