Nokea
An adult had exploratory surgery and postoperatively had an exacerbation of asthma. The client is on a rebreathing mask and seems upset and angry. What is the best nursing approach?
- A. Ask the physician for an order for lorazepam (Ativan).
- B. Spend some time with the client.
- C. Ask the family to have someone stay with the client.
- D. Apply wrist restraints.
Correct Answer: B
Rationale: Spending time with the client addresses emotional distress, calming them without medication or restraints, supporting asthma management.
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A client who is withdrawing from alcohol says to the nurse, 'There are snakes on the wall.' Which action should the nurse take initially?
- A. Reassure the client that there are no snakes
- B. Turn the lights on brighter
- C. Tell the client that while he may see snakes, there are really no snakes
- D. Reassure the client that the snakes will not hurt him
Correct Answer: C
Rationale: Acknowledging the hallucination (delirium tremens) as perceived but clarifying reality reduces agitation without confrontation. Reassurance or lighting changes are less effective.
As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid
- A. Surfing
- B. Scuba diving
- C. Parasailing
- D. Swimming
Correct Answer: B
Rationale: Scuba diving. The nurse would strongly emphasize the need for clients with history of spontaneous pneumothorax problems to avoid high altitudes, flying in unpressurized aircraft and scuba diving. The negative pressures could cause the lung to collapse again.
The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated
- A. I can only wear cotton socks.'
- B. I cannot go barefoot around my house.'
- C. I will trim corns and calluses regularly.'
- D. I should ask a family member to inspect my feet daily.'
Correct Answer: C
Rationale: I will trim corns and calluses regularly.' Clients who are elderly, have diabetes, and/or have vascular disease often have decreased circulation and sensation in one or both feet. Their vision may also be impaired. Therefore, they need to be taught to examine their feet daily or have someone else do so. They should wear cotton socks which have not been mended, and always wear shoes when out of bed. They should not cut their nails, corns, and calluses, but should have them trimmed by their provider, nurse, or another provider who specializes in foot care.
A 75-year-old man following a right total hip replacement. The nurse's notes indicate that since the surgery the patient has become disoriented and confused at night. One evening as the nurse prepares the patient for sleep, the patient glances to his left and says, 'Oh, you think so?' and starts to laugh.
Which of the following responses by the nurse is the BEST?
- A. Do you hear voices talking to you?'
- B. Tell me why you are laughing so I can laugh too.'
- C. What is it that you find amusing?'
- D. I notice you're laughing.'
Correct Answer: D
Rationale: Strategy: Remember therapeutic communication. (1) yes/no question, may make client defensive and block communication (2) feeds into client's altered-reality state, nurse should suspect a hallucination (3) confrontation would block communication (4) correct-therapeutic statement of client's nonverbal communication
The nurse is caring for a client with a history of burn injuries.
- A. Which intervention is most important for a client with major burn injuries?
- B. Maintain strict aseptic technique.
- C. Administer oral fluids to prevent dehydration.
- D. Apply cold compresses to burn sites.
- E. Restrict protein intake.
Correct Answer: A
Rationale: Strict aseptic technique prevents infection, a major cause of mortality in burn patients due to loss of skin barrier. IV fluids are used, cold compresses worsen tissue damage, and high-protein diets support healing.