Nokea
Following major abdominal surgery, a client postoperative refuses to use the incentive spirometer. What is the nurse's priority?
- A. Determine the reason why the client is refusing to use the incentive spirometer.
- B. Insist that the client use the incentive spirometer.
- C. Administer pain medication to help the client use the spirometer.
- D. Document the refusal in the client's medical record.
Correct Answer: A
Rationale: The nurse's priority in this situation is to determine the reason why the client is refusing to use the incentive spirometer. By understanding the client's concerns or barriers, the nurse can address them effectively and encourage the client to use the spirometer for optimal postoperative recovery. Insisting that the client use the spirometer without understanding the underlying reason may lead to further resistance. Administering pain medication as a solution does not address the root cause of refusal and may not be necessary if pain is not the primary reason for refusal. Documenting the refusal is important but should come after understanding the client's perspective to provide appropriate care and follow-up.
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The nurse is preparing to administer a subcutaneous injection of insulin to a client with diabetes. What is the best site for the nurse to select for this injection?
- A. Ventrogluteal site
- B. Dorsogluteal site
- C. Deltoid site
- D. Abdomen
Correct Answer: D
Rationale: The correct answer is 'D: Abdomen.' The abdomen is the best site for insulin injections as it provides a larger area with consistent absorption rates due to the high vascularity of the area. The subcutaneous tissue in the abdomen allows for a more predictable and consistent absorption of insulin compared to other sites. Ventrogluteal and dorsogluteal sites are not commonly used for insulin injections due to the risk of hitting the sciatic nerve or causing tissue damage. The deltoid site is more commonly used for intramuscular injections rather than subcutaneous injections like insulin.
A client has restraints on each extremity. Which of the following assessments should the nurse perform first?
- A. Peripheral pulses
- B. Comfort level
- C. Elimination needs
- D. Skin integrity
Correct Answer: A
Rationale: When a client is restrained, the nurse should prioritize assessing peripheral pulses first. This assessment is crucial to monitor circulation and ensure the restraints are not impeding blood flow. Comfort level, elimination needs, and skin integrity are also important assessments; however, assessing peripheral pulses takes precedence to prevent complications such as impaired circulation and tissue damage. By assessing peripheral pulses initially, the nurse can promptly identify and address any circulation issues, which are critical in preventing serious complications.
A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?
- A. A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.
- B. The nurse avoids discussing the client's diagnosis to prevent emotional distress.
- C. The nurse provides a vague answer about the client's condition.
- D. The nurse promises to provide information only if it is requested by the client.
Correct Answer: A
Rationale: Veracity involves telling the truth, a fundamental ethical principle in healthcare. In this scenario, the nurse demonstrates veracity by responding honestly when the client directly asks about her cancer diagnosis. Choice B is incorrect as avoiding discussing the diagnosis to prevent emotional distress does not align with veracity and transparency. Choice C is incorrect as providing a vague answer does not uphold the principle of truthfulness. Choice D is incorrect because promising to provide information only upon client request does not address the immediate question about the cancer diagnosis and lacks transparency.
A healthcare professional is providing teaching to a client who had a new medication prescription. Which of the following manifestations of a mild allergic reaction should the professional include?
- A. Urticaria
- B. Ptosis
- C. Nausea
- D. Hematuria
Correct Answer: A
Rationale: Urticaria, also known as hives, is a common manifestation of a mild allergic reaction. It presents as raised, red, itchy welts on the skin. Ptosis is drooping of the upper eyelid and is not typically associated with allergic reactions. Nausea is a gastrointestinal symptom that can occur with various conditions but is not specific to allergic reactions. Hematuria, which is the presence of blood in the urine, is not a typical manifestation of an allergic reaction.
To use proper body mechanics while making an occupied bed for a client on bed rest, the nurse should:
- A. Place the bed in a high horizontal position
- B. Use a low bed position
- C. Bend at the waist
- D. Keep the bed flat and at a comfortable working height
Correct Answer: A
Rationale: When making an occupied bed for a client on bed rest, the nurse should place the bed in a high horizontal position to promote better body mechanics. This positioning helps reduce strain on the nurse's back and promotes proper alignment while working. Using a low bed position can lead to awkward bending and increased risk of musculoskeletal injuries. Bending at the waist is discouraged as it can strain the back. Keeping the bed flat and at a comfortable working height may not provide the optimal ergonomic setup needed to prevent injury.