Nokea
After a renal biopsy, a client has returned to the unit. Which of the following nursing interventions is appropriate?
- A. Ambulate the client 4 hours after the procedure
- B. Maintain the client on NPO status for 24 hours
- C. Monitor vital signs
- D. Change the dressing every 8 hours
Correct Answer: C
Rationale: Monitoring vital signs is crucial after a renal biopsy to promptly detect any signs of bleeding or complications. Ambulating the client 4 hours after the procedure may increase the risk of bleeding, so it is not appropriate. Maintaining the client on NPO status for 24 hours is not necessary unless specifically ordered by the healthcare provider. Changing the dressing every 8 hours is not typically indicated unless there is a specific concern or order to do so.
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During passive range of motion (ROM) exercises, how should the nurse perform each movement for a patient with impaired mobility?
- A. The nurse moves each movement just to the point of resistance.
- B. The patient repeats each movement 5 times.
- C. The movement continues until the patient reports pain.
- D. The nurse completes each movement quickly and smoothly.
Correct Answer: A
Rationale: During passive range of motion (ROM) exercises, the nurse is responsible for moving the patient's joints through their range of motion. The correct technique involves performing movements slowly and smoothly, only going to the point of resistance without causing pain. This technique helps maintain joint flexibility and prevent contractures. Choice A is the correct answer as it reflects the appropriate technique for passive ROM exercises. Choices B and C are incorrect because the patient is not actively participating, and ROM exercises should not cause pain. Choice D is incorrect as movements should be done deliberately and not quickly.
A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process?
- A. "I will determine the most important client problems that we should address."
- B. "I will review the past medical history on the client's record to gather more information."
- C. "I will carry out the new prescriptions from the provider."
- D. "I will ask the client if their nausea has resolved."
Correct Answer: A
Rationale: In the nursing process, the planning step involves determining priorities and goals based on the identified problems. Choice A is correct as it reflects the nurse's role in identifying the most important client problems to address, which aligns with the planning phase. Choices B, C, and D are incorrect. Choice B involves data collection, which is a part of the assessment phase, not planning. Choice C pertains to the implementation of care, which occurs after the planning phase. Choice D involves evaluation of a specific intervention, not planning.
The healthcare provider is caring for a client with dehydration. Which assessment finding indicates that the client is responding to treatment?
- A. Dry mucous membranes
- B. Increased urine output
- C. Decreased heart rate
- D. Elevated blood pressure
Correct Answer: B
Rationale: Increased urine output is the correct assessment finding that indicates the client is responding to treatment for dehydration. When a client is dehydrated, their urine output tends to decrease as the body tries to conserve fluids. Therefore, an increase in urine output suggests that the client's hydration status is improving. Dry mucous membranes (Choice A) are a sign of dehydration and would not indicate a positive response to treatment. Decreased heart rate (Choice C) and elevated blood pressure (Choice D) are not specific indicators of hydration status in a client with dehydration.
A client is being taught how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?
- A. The client's belief that his needs will be met through education
- B. The nurse's empathy regarding the client's self-injection
- C. The client seeking family approval by agreeing to a teaching plan
- D. The nurse explaining the need for education to the client
Correct Answer: A
Rationale: The client's belief that his needs will be met through education is the most likely factor to increase motivation to learn. When individuals perceive that their educational efforts will directly benefit them, they are more motivated to engage in the learning process. Empathy from the nurse, seeking family approval, or the nurse explaining the need for education may not be as directly tied to the client's personal benefit and may not necessarily increase motivation to learn.
A client's readiness to learn about insulin administration is being assessed by a nurse. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
- A. ''I can concentrate best in the morning.''
- B. ''It is difficult to read the instructions because my glasses are at home.''
- C. ''I'm wondering why I need to learn this.''
- D. ''You will have to talk to my wife about this.''
Correct Answer: A
Rationale: Choice A is the correct answer because the client's statement about the best time to concentrate indicates readiness for learning. This statement shows an awareness and interest in learning. Choice B is incorrect as it indicates a barrier to learning due to not having glasses. Choice C is incorrect as it shows a lack of understanding or motivation for learning. Choice D is incorrect as it suggests a lack of personal involvement or responsibility in the learning process since the client is deflecting the responsibility to someone else.