Nokea
An ulcerated foot peronet (FP) is to be implemented. The UAPs state they have not yet been educated on this before charging assignments.What action should the nurse take first?
- A. Send the UAP to be educated on how to care for a foot ulcer.
- B. Advise the UAP to wear gloves when caring for the FP.
- C. Instruct the UAP to start with basic wound care precautions.
- D. Ask the UAP which action they would take first and state why.
Correct Answer: A
Rationale: It is important for the UAP to receive proper education and training on how to care for a foot ulcer before being assigned to care for a client with this condition.
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A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate.Which action should the nurse take to evaluate the client for urinary retention?
- A. Review the chart for number of voids over the last 24 hours.
- B. Evaluate the client for urinary incontinence.
- C. Scan the client's bladder after voiding.
- D. Palpate the suprapubic region for distention.
Correct Answer: C
Rationale: This will help determine if there is any residual urine left in the bladder after voiding.
The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago.Which intervention should the nurse implement next?
- A. Ask the UAP to offer back rubs to the client.
- B. Reassess the client and the level of pain.
- C. Encourage the client to focus on taking deep breaths.
- D. Tell the client the medication needs more time to work.
Correct Answer: B
Rationale: The nurse should reassess the client's pain level and determine if additional interventions are needed to manage the pain.
A client who had emergency gallbladder surgery yesterday is getting ready to be discharged.The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?
- A. Have the client demonstrate prescribed wound care.
- B. Provide written instructions in the client's native language.
- C. After each instruction, ask the client if he/she understands.
- D. Have an interpreter repeat the wound care instructions.
Correct Answer: A
Rationale: The best way to evaluate the client's understanding of self-care at home is to have the client demonstrate prescribed wound care. This allows the nurse to directly observe the client's ability to perform the necessary tasks and provide feedback and clarification as needed.
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies.Which of the following is most useful for the nurse to include?
- A. Providing physical demonstration.
- B. Using simulation activities.
- C. Incorporating verbal analogies.
- D. Offering positive reinforcement.
Correct Answer: B
Rationale: Simulation activities provide a safe and controlled environment for young adult clients to practice problem-solving strategies and learn from their experiences.
The healthcare provider prescribes ear drops to an adult client with an ear infection.Which exacting should the nurse follow?
- A. Swab and shake bottle before administering the drops.
- B. Administer the drops with the head tilted upright.
- C. Lower the edge of the dropper into the canal of the ear.
- D. Keep the patient in supine position to administer the drops
Correct Answer: D
Rationale: When administering ear drops to an adult client with an ear infection, the nurse should keep the patient in a supine position to administer the drops. This position allows the medication to flow into the ear canal and reach the site of infection.