Nokea
Complete the following sentence by using the lists of options.The client is at highest risk for developing---- as evidenced by the client's-------
- A. endometritis
- B. mastitis
- C. perineal hematoma
- D. large for gestational age newborn
- E. group B streptococcus
- F. tracked nipple
Correct Answer: B,F
Rationale: Cracked nipples increase the risk of mastitis, especially in breastfeeding mothers.
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A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the nurse plan to use during the group session?
- A. Encourage clients to establish a timeline for their own grieving process.
- B. Initiate a discussion with clients about ways to cope with changes in family dynamics.
- C. Assist clients in identifying ways suicide could have been prevented
- D. Discourage clients from sharing negative aspects of their relationship with the deceased person
Correct Answer: B
Rationale: The correct answer is B: Initiate a discussion with clients about ways to cope with changes in family dynamics. This is the most appropriate strategy as it addresses the immediate impact of the suicide on family dynamics and helps clients develop coping mechanisms. Discussing coping strategies can empower clients to navigate the difficult changes they are facing.
A: Encouraging clients to establish a timeline for their own grieving process may not be helpful as each individual grieves differently and timelines can vary significantly.
C: Assisting clients in identifying ways suicide could have been prevented may lead to feelings of guilt and self-blame, which can be harmful to the healing process.
D: Discouraging clients from sharing negative aspects of their relationship with the deceased person can hinder the expression of emotions and the processing of complex feelings related to the loss.
Which of the following actions should the nurse plan to take?
- A. Position the client on the affected side for 4 hr following the procedure
- B. Instruct the client to avoid coughing during the procedure
- C. Inform the client that he will be NPO for 6 hr prior to the procedure
- D. Place the client in the prone position during the procedure,
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to avoid coughing during the procedure. This is crucial because coughing can disrupt the procedure, leading to potential complications. Coughing can cause movement that may interfere with the accuracy of the procedure or cause injury to the client. Positioning the client on the affected side (A) for 4 hours following the procedure is not necessary and can lead to discomfort. Informing the client that they will be NPO for 6 hours prior to the procedure (C) may not be relevant depending on the type of procedure. Placing the client in the prone position during the procedure (D) can be risky and uncomfortable for the client.
A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?
- A. I cannot be a witness for your consent to donate.
- B. You must be at least 21, years of age to become an organ donorâ€
- C. Your desire to be an organ donor must be documented in writingâ€
- D. Your name cannot be removed once you are listed on the organ donor list.
Correct Answer: C
Rationale: The correct response should be C: "Your desire to be an organ donor must be documented in writing." This is the correct answer because in order for someone to become an organ donor, their decision must be documented in writing, typically through an organ donor card, a driver's license designation, or registration with a national organ donation registry. This documentation is crucial to ensure that the individual's wishes are respected and followed in the event of their death.
The other choices are incorrect:
A: "I cannot be a witness for your consent to donate." This statement is incorrect as a nurse can provide information and support regarding organ donation, but they are not required to be a witness for consent.
B: "You must be at least 21 years of age to become an organ donor." This statement is incorrect as the legal age requirement to become an organ donor varies by country or state, and it is not always 21 years of age.
D: "Your name cannot be removed once you are listed
Which of the following statements by the client indicates an understanding of the teaching?
- A. I should keep the medication in the original container.
- B. I should replace any unused medication every 6 months.
- C. I can store the medication in the refrigerator.
- D. I can crush the medication and mix with applesauce.
Correct Answer: A
Rationale: The correct answer is A because keeping medication in the original container ensures proper identification, dosage, and expiration monitoring. Choice B is incorrect as replacing unused medication every 6 months may lead to waste. Choice C is incorrect as not all medications should be stored in the refrigerator. Choice D is incorrect as crushing medication may alter its effectiveness or cause harm. It is important for the client to understand the importance of following specific storage instructions provided with the medication, making choice A the most appropriate response.
A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take?
- A. Administer oral acetaminophen.
- B. Cover the adolescent with a thermal blanket
- C. Submerge the adolescent's feet in ice water
- D. Initiate seizure precautions.
Correct Answer: D
Rationale: The correct answer is D: Initiate seizure precautions. Hyperthermia can lead to seizures due to the brain's sensitivity to high temperatures. Seizure precautions involve ensuring a safe environment, padding the bed, and having emergency equipment ready. Administering oral acetaminophen (A) is not the priority in hyperthermia as it may not rapidly reduce the temperature. Covering with a thermal blanket (B) may further increase body temperature. Submerging feet in ice water (C) can cause vasoconstriction and shivering, leading to increased core temperature.