Nokea
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 caring for a client who is scheduled to have a colonoscopy. The client states, 'I am so nervous about what the doctor might find during the test.' The nurse asks the client, 'Are you feeling anxious about the results of your colonoscopy?' The nurse's response is an example of which of the following communication techniques?
- A. Clarification
- B. Self-disclosure
- C. Sharing observations
- D. Providing information
Correct Answer: A
Rationale: Clarification helps the nurse ensure understanding of the client's concerns.
A nurse is reinforcing teaching about health promotion with a group of older adults. Which of the following health promotion measures should the nurse recommend? (Select all that apply.)
- A. Yearly blood pressure screening
- B. Use of lotions with a SPF of 15 or higher
- C. Immunization for influenza
- D. Annual visual acuity screening
- E. Reduce calcium intake.
Correct Answer: A,B,C,D
Rationale: Correct Answer: A, B, C, D
Rationale:
A: Yearly blood pressure screening is important for early detection and management of hypertension, a common health issue in older adults.
B: Using lotions with SPF of 15 or higher helps prevent skin damage and reduces the risk of skin cancer, a common concern in older adults.
C: Immunization for influenza is crucial in older adults to prevent serious complications from the flu due to their weakened immune systems.
D: Annual visual acuity screening is essential for detecting age-related vision changes and preventing accidents or falls.
Summary:
E: Reducing calcium intake is not a recommended health promotion measure for older adults, as adequate calcium is essential for bone health and preventing osteoporosis.
A nurse is evaluating an older adult client who is receiving end-of-life care and has Cheyne-Stokes respirations. Which of the following observations should the nurse identify as confirmation of this respiratory pattern?
- A. Breathing ranging from very deep to very shallow with periods of apnea
- B. Shallow breathing alternating with periods of apnea
- C. Rapid respirations that are unusually deep and regular
- D. An inability to breathe without dyspnea unless sitting upright
Correct Answer: A
Rationale: The correct answer is A: Breathing ranging from very deep to very shallow with periods of apnea. Cheyne-Stokes respirations are characterized by a cyclical pattern of breathing that starts with shallow breaths and gradually becomes deeper, followed by a period of apnea. This pattern repeats itself. Option B is incorrect because it describes shallow breathing alternating with periods of apnea, which is not characteristic of Cheyne-Stokes respirations. Option C describes rapid and deep regular respirations, which is not consistent with Cheyne-Stokes respirations. Option D describes an inability to breathe without dyspnea unless sitting upright, which is not a feature of Cheyne-Stokes respirations. It is important for the nurse to be able to identify this specific respiratory pattern in the older adult client to provide appropriate care and support.
A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?
- A. Discontinue the enema.
- B. Lower the height of the solution bag.
- C. Continue the enema and reassure the client.
- D. Pause the enema and give the client pain medication.
Correct Answer: B
Rationale: Correct Answer: B - Lower the height of the solution bag.
Rationale: Lowering the height of the solution bag will decrease the flow rate of the enema, which can help alleviate the mild cramping the client is experiencing. This adjustment can make the procedure more tolerable for the client without needing to discontinue it entirely. It is important to address the client's discomfort while ensuring the effectiveness of the enema.
Summary of other choices:
A: Discontinuing the enema may not be necessary if the client's discomfort can be managed with a simple adjustment.
C: Continuing the enema without addressing the client's discomfort may lead to increased distress.
D: Pausing the enema and giving pain medication is not the initial intervention for mild cramping and may not be necessary if a simple adjustment can alleviate the discomfort.
A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?
- A. Provide the client with a high fiber diet.
- B. Administer a soap-suds enema to cleanse the colon.
- C. Allow the perineal area to air dry after each stool.
- D. Apply an alcohol-free barrier to the perineal area after each stool.
Correct Answer: D
Rationale: An alcohol-free barrier protects the skin from irritation due to frequent stooling.