Nokea
By the 2nd post-op day
- A. a client has not achieved satisfactory pain relief. What should the nurse do next according to the nursing process?
- B. Reassess client to determine reasons for pain
- C. See whether pain lessens during next 24h
- D. Change plan to ensure adequate pain relief
- E. Teach client about pain management plan
Correct Answer: A
Rationale: Correct Answer: A
Rationale: By the 2nd post-op day, if a client has not achieved satisfactory pain relief, the nurse should follow the nursing process. This involves reassessment to identify the reasons for inadequate pain relief, which is essential for developing an effective plan to address the client's pain. The nurse should not simply wait to see if the pain lessens or immediately change the pain management plan without first understanding the underlying reasons. Additionally, teaching the client about the pain management plan may be important but not the immediate priority if the pain relief is not satisfactory. It is crucial to first assess the situation comprehensively before making any changes to the plan.
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Nurse is talking with parents of toddler. Which should nurse suggest regarding discipline?
- A. Establish consistent boundaries
- B. Place him in room with door closed
- C. Have him learn by trial & error
- D. Use favorite snacks as rewards
Correct Answer: A
Rationale: The correct answer is A: Establish consistent boundaries. This is important because toddlers thrive on routine and predictability. Consistent boundaries help them understand what is expected of them and provide a sense of security. Choice B is inappropriate as isolating a child can lead to feelings of abandonment. Choice C is ineffective as toddlers need guidance and supervision to learn appropriate behavior. Choice D may lead to unhealthy eating habits and does not address the underlying behavior.
Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed?
- A. So I don't need colon cancer procedure for another 2-3 yrs
- B. For now, I should continue to have mammogram each year
- C. B/c doctor just did pap smear, I'll come back next year for another
- D. I had my blood glucose test last year so I won't need it again till next year
Correct Answer: B
Rationale: The correct answer is B. The client's statement indicates an understanding of the recommended screening guideline for mammograms for a 45-year-old individual with no specific family history of cancer. Yearly mammograms are typically recommended starting at age 40 for early detection of breast cancer. Choice A is incorrect as colon cancer screening is recommended starting at age 45-50, not in 2-3 years. Choice C is incorrect as Pap smears are typically recommended every 3-5 years, not yearly. Choice D is incorrect as blood glucose testing is usually recommended annually for individuals at risk for diabetes.
Nurse caring for 5 yo whose parents report she fears painful procedures, like shots. Which strategies should nurse use to try to help ease child's fear? (Select all that apply.)
- A. Invite child to assist with mealtime activities
- B. Cluster invasive procedures whenever possible
- C. Assign caregivers with whom the child is familiar
- D. Have parents bring in favorite toy from home
- E. Engage child in pretend play with toy medical kit
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Inviting the child to assist with mealtime activities can help build trust and rapport, making the child more comfortable with the nurse.
D: Having parents bring in the child's favorite toy from home can provide comfort and distraction during procedures.
E: Engaging the child in pretend play with a toy medical kit can help familiarize the child with medical procedures in a non-threatening way.
Summary:
B: Clustering invasive procedures may not directly address the child's fear and can still be overwhelming.
C: Assigning caregivers familiar to the child may help in general care but may not directly address the fear of painful procedures.
F, G: No additional answer choices provided.
A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?
- A. Each movement is repeated 5 times by the patient.
- B. Each movement is performed until the patient experiences pain.
- C. Each movement is completed quickly and smoothly by the nurse.
- D. Each movement is moved just to the point of resistance by the nurse.
Correct Answer: D
Rationale: The correct answer is D because moving each joint just to the point of resistance during passive ROM exercises helps prevent injury and avoids causing pain to the patient. Moving beyond the point of resistance can result in muscle strain or joint damage. This technique allows the nurse to safely improve joint mobility without causing harm.
Choice A is incorrect because the patient may not be able to repeat the movement 5 times due to their impaired mobility. Choice B is incorrect because continuing movement until the patient experiences pain is harmful and can lead to injury. Choice C is incorrect because moving quickly and smoothly may not allow the nurse to gauge the patient's tolerance and could potentially cause harm.
Nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which bed position is appropriate for safe care of this client?
- A. Supine
- B. Semi-Fowler's
- C. Semi-prone
- D. Trendelenburg
Correct Answer: B
Rationale: The correct answer is B: Semi-Fowler's. This position helps prevent aspiration during enteral tube feedings by promoting proper digestion and reducing the risk of reflux. Semi-Fowler's allows gravity to assist in the movement of food through the gastrointestinal tract, decreasing the likelihood of regurgitation. Supine (A) can increase the risk of aspiration as it may cause reflux. Semi-prone (C) and Trendelenburg (D) positions are not recommended for enteral feedings due to increased risk of reflux and aspiration.