Nokea
A provider is discharging a client with a prescription for home oxygen therapy. The nurse should reinforce which of the following instructions with the client and his family? (Select all that apply.)
- A. Cleanse the mask or collar with soapy water every other day.
- B. Make sure the straps on the mask are secure but not too tight.
- C. Check the tops of his ears regularly for skin breakdown.
- D. Post 'no smoking' warning signs at home in a prominent location.
- E. Apply petroleum jelly around and inside the nares.
Correct Answer: B,C,D
Rationale: Correct Answer: B, C, D
Rationale:
B: Making sure the straps on the mask are secure but not too tight is essential to ensure proper oxygen delivery without discomfort or skin irritation.
C: Checking the tops of the ears regularly for skin breakdown is important as the oxygen tubing can cause pressure and skin breakdown in this area.
D: Posting 'no smoking' warning signs at home in a prominent location is crucial as oxygen is highly flammable and can lead to a fire hazard if exposed to smoking or open flames.
Summary:
A: Cleansing the mask or collar with soapy water every other day is not necessary for home oxygen therapy as frequent cleaning can damage the equipment.
E: Applying petroleum jelly around and inside the nares is not recommended as it can interfere with oxygen delivery and cause respiratory issues.
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A nurse is contributing to the plan of care for a client who practices the Muslim faith. Which of the following actions should the nurse include in the plan?
- A. Serve foods that have a hot/cold balance.
- B. Serve milk products prior to meals
- C. Request a meal tray without pork.
- D. Remove tea and coffee from meal trays.
Correct Answer: C
Rationale: Muslim dietary laws prohibit pork, so meals should be planned accordingly.
A nurse is assisting with speaking in front of a group of nurses about new guidelines to prevent pressure ulcers. Which of the following actions by the nurse demonstrates confidence?
- A. The nurse stands tall before talking.
- B. The nurse paces back and forth while making the speech.
- C. The nurse looks down at her notes for the duration of the talk.
- D. The nurse taps her foot repeatedly during the speech.
Correct Answer: A
Rationale: Standing tall with good posture conveys confidence and authority while speaking.
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 assisting with an education program about breast self-examinations. Which of the following information should the nurse include?
- A. Perform breast self-examinations 1 week following menses.
- B. Palpate the breasts using a left to right motion.
- C. Express discharge from the nipple each month.
- D. Avoid performing breast self-examinations while showering.
Correct Answer: A
Rationale: The correct answer is A: Perform breast self-examinations 1 week following menses. This timing is ideal because breasts are less likely to be tender or swollen during this time, making it easier to detect any abnormalities. Performing the exam at the same time each month helps in noticing changes. Option B is incorrect because the recommended motion is in a circular pattern. Option C is incorrect because expressing discharge is not a part of breast self-examination. Option D is incorrect as performing the exam in the shower is actually beneficial due to the slippery nature of wet skin, aiding in smooth palpation.
A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse ask to promote this discussion?
- A. What brought you to the hospital?
- B. Would you tell me about all of your medical issues?
- C. Do you want to talk about your health concerns?
- D. Would it help to discuss your feelings about this hospitalization?
Correct Answer: A
Rationale: The correct answer is A: "What brought you to the hospital?" This question is open-ended and encourages the client to share their reason for seeking medical care, providing valuable information for the nurse to assess the client's health needs. Choice B is too broad and may overwhelm the client. Choice C puts the onus on the client to initiate the discussion. Choice D focuses on emotions rather than the primary reason for the hospitalization.