Nokea
An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?
- A. Help the client write down the questions to ask the provider, so that the client doesn't forget
- B. Reassure the client that everything will be explained
- C. Explain the procedure in detail yourself
- D. Direct the client to search for information online
Correct Answer: A
Rationale: Assisting the client in preparing questions is the most appropriate action as it helps ensure that all concerns are addressed during the provider's visit. By helping the client write down questions, the nurse empowers the client to actively participate in their care and communicate effectively with the provider. Reassuring the client, while well-intentioned, may not address the specific questions or fears the client has. Explaining the procedure in detail may not be what the client is seeking at this moment, as their primary concern is about the provider's actions. Directing the client to search for information online is not recommended as it may lead to confusion or misinformation, and the information may not be tailored to the client's specific situation.
You may also like to solve these questions
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the LPN give the client about this medication?
- A. Prolonged use does not typically cause dark concentrated urine.
- B. It is not necessary to take the medication on an empty stomach for optimal absorption.
- C. Avoid taking the medication with aluminum hydroxide to minimize GI upset.
- D. Drinking alcohol daily can cause drug-induced hepatitis.
Correct Answer: D
Rationale: The correct answer is D. When taking isoniazid, alcohol consumption should be avoided as it can increase the risk of liver damage, potentially leading to drug-induced hepatitis. Choices A, B, and C are incorrect. Prolonged use of isoniazid does not typically cause dark concentrated urine; it is not necessary to take the medication on an empty stomach for optimal absorption; and it is not recommended to take isoniazid with aluminum hydroxide to minimize GI upset.
A healthcare provider is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the healthcare provider take?
- A. Insert the IV catheter without using a tourniquet.
- B. Use the tourniquet minimally or not at all to avoid injury to fragile skin or veins.
- C. Insert the IV catheter at a 45-degree angle.
- D. Use a smaller gauge catheter to reduce vein trauma.
Correct Answer: B
Rationale: When initiating IV therapy in older adults, it is essential to use the tourniquet minimally or not at all to prevent potential injury to fragile skin or veins. The use of a tourniquet can lead to increased venous pressure and potentially cause vein damage in older adult clients. Choice A is incorrect because inserting the IV catheter without a tourniquet can make locating veins more challenging. Choice C is incorrect as inserting the IV catheter at a 45-degree angle is not a recommended practice and can increase the risk of complications. Choice D is incorrect because using a smaller gauge catheter may not be appropriate for older adults who may require a larger gauge catheter for adequate fluid administration.
The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed.
- A. Administer nasal oxygen at a rate of 5 L/min
- B. Help the client to lie back down in the bed
- C. Quickly pivot the client to the chair and elevate the legs
- D. Check the client's blood pressure and pulse deficit
Correct Answer: D
Rationale: Checking the client's blood pressure and pulse deficit is essential before mobilizing a client out of bed, especially after surgery. This assessment helps ensure the client's stability and readiness for mobilization. Administering oxygen or pivoting the client without prior assessment could pose risks if the client is not medically stable. Helping the client lie back down without proper evaluation may delay necessary interventions if the client is indeed ready for mobilization.
A nurse is planning care for a client who had a stroke. What task should be assigned to the assistive personnel?
- A. Assist the client with a partial bed bath
- B. Measure the client's blood pressure after the nurse administers antihypertensive medications
- C. Use a communication board to ask what the client wants for lunch
- D. Feed the client
Correct Answer: A
Rationale: The correct answer is to assign the assistive personnel to assist the client with a partial bed bath. This task falls within the scope of practice for assistive personnel and is a common activity in caring for clients who have had a stroke. Choice B involves measuring blood pressure, which should be done by a licensed nurse. Choice C requires the use of a communication board, which can be done by any healthcare team member, not just assistive personnel. Choice D involves feeding the client, which may require assessment and intervention by a licensed nurse to ensure proper nutrition and safety.
The healthcare provider is assessing a client with a history of congestive heart failure. Which assessment finding would be most concerning?
- A. Shortness of breath on exertion
- B. Weight gain of 2 pounds in a week
- C. Orthopnea
- D. Crackles in the lungs
Correct Answer: D
Rationale: Crackles in the lungs are concerning because they indicate pulmonary congestion, a serious complication of congestive heart failure. The presence of crackles suggests fluid accumulation in the lungs, requiring immediate attention to prevent respiratory distress and worsening heart failure. While shortness of breath on exertion, weight gain, and orthopnea are common signs and symptoms of heart failure, crackles specifically point to acute pulmonary edema or worsening congestion, making them the most concerning finding in this scenario.