Nokea
A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development?
- A. Becoming actively involved in providing guidance to the next generation
- B. Adjusting to major changes in roles and relationships due to losses
- C. Devoting a great deal of time to establishing an occupation
- D. Finding oneself 'sandwiched' in between & being responsible for two generations
Correct Answer: C
Rationale: The correct answer is C: Devoting a great deal of time to establishing an occupation. This is an example of appropriate psychosocial development for a young adult as per Erikson's theory of psychosocial development. During the stage of young adulthood, individuals focus on establishing their careers and personal identities. This is a crucial developmental task during this stage, as it helps individuals gain a sense of purpose and direction in life. Choices A, B, and D involve responsibilities and challenges more commonly associated with other stages of life, such as middle adulthood or late adulthood. Therefore, they are not appropriate examples of psychosocial development for a young adult.
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A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform prior to beginning the procedure? Select all.
- A. Review a signal the client can use if feeling any distress.
- B. Lay a towel across the client's chest.
- C. Administer oral pain meds.
- D. Obtain a Dobhoff tube for insertion.
- E. Have a petroleum-based lubricant available.
Correct Answer: A, B
Rationale: Correct Answer: A, B
Rationale:
A: Review a signal the client can use if feeling any distress - This is important to ensure the client can communicate any discomfort or issues during the procedure.
B: Lay a towel across the client's chest - Helps protect the client's clothing and bedding from potential spillage during the procedure.
C: Administer oral pain meds - Not necessary prior to NG tube insertion for gastric decompression.
D: Obtain a Dobhoff tube for insertion - Dobhoff tube is not typically used for gastric decompression with NG tube.
E: Have a petroleum-based lubricant available - Lubricant is required for NG tube insertion but not specifically petroleum-based.
F:
G:
Summary: Choices C, D, and E are not necessary prior to beginning the NG tube insertion procedure. Choice A and B are essential steps to ensure patient safety and comfort during the process.
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?
- A. Have the client hold his breath briefly
- B. Discontinue the fluid instillation
- C. Remind the client that cramping is common at this time
- D. Lower the enema fluid container
Correct Answer: D
Rationale: The correct answer is D: Lower the enema fluid container. This intervention helps slow down the flow of the enema solution, reducing the client's discomfort from cramping. By lowering the container, the rate of fluid instillation decreases, giving the client's body more time to adjust to the enema. This action promotes better tolerance and helps alleviate abdominal cramping.
Other choices are incorrect:
A: Having the client hold his breath briefly does not address the underlying cause of the cramping and may increase discomfort.
B: Discontinuing the fluid instillation abruptly can cause incomplete cleansing and may not address the cramping effectively.
C: Merely reminding the client that cramping is common does not provide immediate relief or help manage the discomfort.
By choosing option D, the nurse can effectively manage the client's cramping during the enema procedure.
A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all.
- A. Repeat the details of the prescription back to the provider
- B. Have another nurse listen to the telephone prescription
- C. Obtain the prescriber's signature on the prescription within 24hrs
- D. Decline the verbal prescription because it is not an emergency situation
- E. Tell the charge nurse that the provider has prescribed morphine by telephone
Correct Answer: A, B, C
Rationale: The correct choices are A, B, and C. A nurse should repeat the prescription back to the provider to ensure accurate communication and prevent errors. Having another nurse listen to the prescription can provide an additional check for accuracy and clarity. Obtaining the prescriber's signature on the prescription within 24 hours is necessary for documentation and legal purposes. Choice D should be ruled out as it is not appropriate to decline a valid prescription for pain medication in a timely manner. Choice E does not address the immediate need to confirm and document the prescription accurately.
A client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse who is providing preop care regarding informed consent? Select all.
- A. Make sure the surgeon obtained the client's consent
- B. Witness the client's signature on the consent form
- C. Explain the risks and benefits of the procedure
- D. Describe the consequences of choosing not to have the surgery
- E. Tell the client about alternatives to having the surgery
Correct Answer: A, B
Rationale: Correct Answer: A, B
Rationale:
A: The nurse should ensure the surgeon obtained the client's consent as the surgeon is responsible for informing the client about the procedure and obtaining consent.
B: Witnessing the client's signature on the consent form ensures that the client signed voluntarily and with full understanding.
Summary:
C: While explaining risks and benefits is important, it is primarily the surgeon's responsibility.
D: Describing consequences of not having surgery is relevant but not directly related to obtaining informed consent.
E: Although discussing alternatives is crucial, it is not a direct part of the informed consent process.
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? Select all.
- A. Apply the oxygen source loosely if the SPO2 decreases during the procedure
- B. Use surgical asepsis to remove & clean the inner cannula
- C. Clean the outer surfaces in a circular motion from the stoma site outward
- D. Replace the tracheostomy ties with new ties
- E. Cut a slit in gauze squares to place beneath the tube holder
Correct Answer: A, B, C
Rationale: The correct actions are A, B, and C. A) Applying the oxygen source loosely if the SPO2 decreases during the procedure ensures adequate oxygenation. B) Using surgical asepsis to remove and clean the inner cannula prevents infection. C) Cleaning the outer surfaces in a circular motion from the stoma site outward helps prevent contamination. Other options are incorrect because: D) Replacing the tracheostomy ties with new ties is not necessary each time. E) Cutting a slit in gauze squares is not a standard practice for tracheostomy care.