Nokea
At what point in the nurse-client relationship should termination first be addressed?
- A. in the working phase
- B. in the termination phase
- C. in the orientation phase
- D. when the client initially brings up the topic
Correct Answer: C
Rationale: The client has a right to know the parameters of the nurse-client relationship. If the relationship is to be time limited, the client should be informed of the number of sessions. If it is open-ended, the termination date is not known at the outset, and the client should know that this is an issue that is negotiated at a later date.
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The client is receiving 2 liters of oxygen by nasal cannula. Which rationale should the nurse use to explain the reason for oxygen being bubbled through a humidifier?
- A. Prevents the burning sensation of direct oxygen
- B. Prevents the drying of the nasal passages
- C. Prevents a chemical reaction between the tubing and oxygen
- D. Prevents contamination with environmental gases
Correct Answer: B
Rationale: B: Humidification prevents nasal passage drying. A: Oxygen doesn't burn. C: No chemical reaction occurs with tubing. D: Environmental gases don't contaminate oxygen.
The LPN is observing a client using crutches for a leg injury. Which of these would indicate a need for more education?
- A. The client places the top padding 1-2 inches below the axilla with a firm grip on the handles.
- B. The client rests the axilla on the top padding and loosely grips the handles with hands.
- C. The client has a slight bend in the elbow when using the handles.
- D. When going down the stairs, the client leads with the injured leg.
Correct Answer: B
Rationale: Resting the axilla on the top of the crutch can cause nerve damage and the client should have a firm grip on the handles.
The nurse is assessing the female client who is 65 inches tall and has a small body frame. Based on the information in the chart illustrated, what is the client's approximate ideal body weight?
Correct Answer: 117
Rationale: Height is 5'5†(65/ 12 = 5 remainder 5). Formula: 105 lb for 5 ft + 5 lb × 5 = 130 lb. Small frame subtracts 10% (130 × 0.1 = 13 lb). 130 − 13 = 117 lb.
For safety, the nurse should ask the client to:
- A. drink 1000 cc prior to the procedure to affect fluid loss.
- B. eat foods low in fat.
- C. empty his bladder prior to the procedure.
- D. assume the prone position.
Correct Answer: C
Rationale: When performing a paracentesis, the client must be sitting up to allow the fluid to settle to the lower abdomen. To prevent trauma to the bladder while inserting a needle to aspirate the fluid, the bladder must be empty.
The death of a beloved spouse places the surviving partner in which type of crisis?
- A. maturational
- B. reactive
- C. nonreactive
- D. situational
Correct Answer: D
Rationale: A situational crisis is an unexpected, unplanned event, such as the death of a spouse. Option 1 is a normal maturational crisis; Choices 2 and 3 are not recognized crisis states.