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A nurse whose left hand is dominant is preparing to perform a straight catheterization for a client who is paraplegic. Which of the following actions should the nurse take?
- A. Use the left hand to cleanse the urinary meatus.
- B. Use the right hand to insert the catheter.
- C. Stand on the client's right side.
- D. Raise the bed to a comfortable working height.
Correct Answer: D
Rationale: The correct answer is D: Raise the bed to a comfortable working height. This is important to prevent strain on the nurse's back and ensure proper ergonomics during the procedure. Standing on the client's right side (Choice C) does not directly impact the procedure. Using the left hand to cleanse the urinary meatus (Choice A) could be challenging for a left-handed nurse and may not be as efficient. Using the right hand to insert the catheter (Choice B) could also be difficult for a left-handed nurse and may affect dexterity. Therefore, raising the bed to a comfortable working height is the most appropriate action to ensure the nurse's comfort and safety while performing the catheterization.
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A nurse is assisting with the readmission of a client to the medical unit after a transfer to ICU following a suicide attempt using an overdose of medication. The client looks down at the floor and mumbles, 'Hello.' Which of the following responses should the nurse make?
- A. You have been transferred back to this unit. This is your new room.
- B. Hello. I see that in ICU you've been getting a light diet. How does your stomach feel now?
- C. I was upset when I found you had tried to kill yourself.
- D. Would you like to talk about what happened?
Correct Answer: D
Rationale: Encouraging open communication provides emotional support and helps the client process their feelings.
A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?
- A. Increase the client's oral fluid intake.
- B. Initiate humidification therapy.
- C. Encourage the client to cough and deep breathe.
- D. Raise the head of the bed.
Correct Answer: D
Rationale: The correct action is to raise the head of the bed (Choice D) first. This helps improve ventilation and oxygenation by optimizing lung expansion and reducing the work of breathing. Elevating the head of the bed promotes better oxygen exchange in pneumonia patients. Increasing oral fluid intake (Choice A) may be beneficial but not the priority in this scenario. Humidification therapy (Choice B) may help with secretions but does not directly address the oxygenation concern. Encouraging cough and deep breathing (Choice C) is important for lung hygiene but should come after ensuring adequate oxygenation.
A nurse is contributing to the plan of care for a client who is a Seventh-Day Adventist. To provide spiritually and culturally sensitive care, which of the following interventions should the nurse suggest for this client?
- A. Do not schedule diagnostic tests for Saturday.
- B. Arrange for him to receive the sacrament of the sick.
- C. Assign same-gender caregivers.
- D. Offer him a kosher dietary menu.
Correct Answer: A
Rationale: The correct answer is A: Do not schedule diagnostic tests for Saturday. Seventh-Day Adventists observe the Sabbath on Saturdays and refrain from work or secular activities. By avoiding scheduling diagnostic tests on Saturdays, the nurse respects the client's religious beliefs and promotes culturally sensitive care.
Incorrect options:
B: Arrange for him to receive the sacrament of the sick - This option pertains to a Catholic sacrament, not relevant to Seventh-Day Adventist beliefs.
C: Assign same-gender caregivers - This is related to privacy and modesty, not specific to Seventh-Day Adventist beliefs.
D: Offer him a kosher dietary menu - Kosher dietary laws are specific to Jewish beliefs, not Seventh-Day Adventist practices.
A nurse is caring for a client who practices Orthodox Judaism. The nurse should identify that which of the following foods together on the same dinner tray violates the client's religious practices?
- A. Kosher roast beef and ice cream
- B. Carrot sticks and cottage cheese
- C. Macaroni and cheese
- D. Kosher chicken breast and boiled potatoes
Correct Answer: A
Rationale: The correct answer is A: Kosher roast beef and ice cream. In Orthodox Judaism, meat and dairy products cannot be consumed together. Kosher laws prohibit mixing meat and dairy in the same meal or on the same plate to maintain dietary restrictions. Choices B, C, and D do not violate this rule as they do not mix meat and dairy products. Carrot sticks and cottage cheese (B), macaroni and cheese (C), and kosher chicken breast and boiled potatoes (D) are all permissible combinations in Orthodox Judaism.
A nurse is caring for a client who practices Orthodox Judaism. The nurse should identify that which of the following foods together on the same dinner tray violates the client's religious practices?
- A. Kosher roast beef and ice cream
- B. Carrot sticks and cottage cheese
- C. Macaroni and cheese
- D. Kosher chicken breast and boiled potatoes
Correct Answer: A
Rationale: The correct answer is A: Kosher roast beef and ice cream. In Orthodox Judaism, dairy and meat products cannot be consumed together. The mixing of meat and dairy violates the dietary laws of Kashrut. Kosher chicken breast and boiled potatoes (choice D) are both permissible to eat together as they are both meat products. Carrot sticks and cottage cheese (choice B) are both dairy products and can be consumed together. Macaroni and cheese (choice C) is a dairy product and can be consumed alone or with other dairy products.