Nokea
A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
- A. Why don¢â‚¬â„¢t we now have the client turn back to the left side.
- B. That was done correctly. Did you have any problems with the insertion?
- C. Let¢â‚¬â„¢s check to see if the suppository is in far enough.
- D. Did you feel any stool in the intestinal tract?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage?
- A. Insert an indwelling urinary catheter.
- B. Limit caloric and protein intake.
- C. Turn the patient every 2 hours.
- D. Assess for pain during a bath.
Correct Answer: D
Rationale: The most important action for preventing skin impairment in a mobile patient with local nerve damage is to assess for pain during a bath. Assessing pain during a bath helps in evaluating sensory nerve function by checking for touch, pain, heat, cold, and pressure. This assessment is crucial in identifying areas of potential skin breakdown and implementing preventive measures. Inserting an indwelling urinary catheter (Choice A) is not directly related to preventing skin impairment in this context. Limiting caloric and protein intake (Choice B) is not pertinent to skin impairment prevention for a mobile patient with local nerve damage. While turning the patient every 2 hours (Choice C) is a good practice for preventing pressure ulcers, in this case, assessing for pain during a bath is more directly related to preventing skin impairment associated with nerve damage.
A nurse receives a report about a client receiving IV fluids infusing at 125 mL/hr but notes they have only received 80 mL over the last 2 hours. What should the nurse do first?
- A. Check IV tubing for obstruction
- B. Increase the flow rate
- C. Change the IV site
- D. Notify the physician
Correct Answer: A
Rationale: The correct first action for the nurse to take is to check the IV tubing for obstruction. This step is crucial in ensuring that the IV fluids are flowing properly and that there are no blockages preventing the correct infusion rate. Increasing the flow rate (Choice B) without confirming the tubing's status could lead to potential complications if there is indeed an obstruction. Changing the IV site (Choice C) is not the priority in this situation unless there are specific clinical indications. Notifying the physician (Choice D) can be done after checking the tubing for obstruction, as the physician may need to be informed depending on the findings.
A healthcare professional is assessing a client's oculomotor nerve functions. Which of the following actions should the healthcare professional take?
- A. Check the client's pupillary reaction to light
- B. Ask the client to read print from the Snellen chart
- C. Ask the client to identify different scents
- D. Use cotton to lightly touch the client's cornea
Correct Answer: A
Rationale: Checking the client's pupillary reaction to light is a key assessment to evaluate the oculomotor nerve function. The oculomotor nerve controls the pupil's constriction response to light. Choices B, C, and D are incorrect because testing vision with a Snellen chart, identifying scents, or touching the cornea are not specific assessments for oculomotor nerve function.
A client is experiencing dyspnea and fatigue after completing morning care. Which of the following actions should the nurse include in the client's plan of care?
- A. Schedule rest periods during morning care.
- B. Discontinue morning care for 2 days.
- C. Perform all care as quickly as possible.
- D. Ask a family member to come in to bathe the client.
Correct Answer: A
Rationale: Scheduling rest periods during morning care is essential for managing dyspnea and fatigue in the client. This approach allows the client to pace themselves and catch their breath, promoting comfort and reducing symptoms. It is crucial to provide breaks to prevent overwhelming the client and exacerbating their symptoms. Discontinuing morning care for 2 days (choice B) is not a suitable solution as it does not address the underlying issue and may lead to neglect of essential care. Performing all care as quickly as possible (choice C) can worsen the client's symptoms and compromise their well-being by increasing stress and exertion. Asking a family member to bathe the client (choice D) does not address the need for rest periods during care and may not be feasible or appropriate in all situations.
Before starting an intensive exercise program, what instruction is most important for the nurse to provide to the client?
- A. Be sure to have a complete physical examination before beginning your planned exercise program.
- B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more.
- C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class.
- D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.
Correct Answer: A
Rationale: Before starting an intensive exercise program, it is crucial for the client to have a complete physical examination. This examination ensures that the client is physically fit to engage in such activities and helps in identifying any underlying health issues that could be exacerbated by the exercise regimen. Choice B is incorrect because it focuses on stress levels related to eating habits rather than the importance of a physical examination for safety. Choice C is incorrect as exercise and stress management classes can complement each other rather than being mutually exclusive. Choice D is incorrect as monitoring weight loss, while important, is not as critical as ensuring the client's physical readiness for the exercise program.