Nokea
Identify the options for communication with each type of client: A client who has suffered a stroke, has expressive aphasia, and has lost use of their dominant hand.
- A. Use written communication and visual aids.
- B. Ask a family member to interpret.
- C. Speak louder and slower.
- D. Use sign language.
Correct Answer: A
Rationale: Written communication and visual aids help bridge the gap caused by expressive aphasia and physical limitations.
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A client who is intubated and has an intra-aortic balloon pump is restless and agitated. What action should the nurse perform first for comfort?
- A. Allow family members to remain at the bedside.
- B. Ask the family if the client would like a fan in the room.
- C. Keep the television tuned to the client's favorite channel.
- D. Speak loudly to the client in case of hearing problems.
Correct Answer: A
Rationale: The correct answer is A: Allow family members to remain at the bedside. This is the priority action as it provides emotional support and comfort to the client. Having familiar faces around can help calm the client and reduce agitation. It also promotes a sense of security and connection.
Choices B, C, and D are incorrect because they do not address the client's immediate need for comfort and emotional support. Asking about a fan, tuning the TV, or speaking loudly do not directly address the client's restlessness and agitation. Prioritizing the presence of family members is essential in this situation.
When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?
- A. Encourage the client and family to be active partners.
- B. Instruct the client to monitor hand hygiene in caregivers.
- C. Offer the family the opportunity to stay with the client.
- D. Advise the client to always wear their armband.
Correct Answer: A
Rationale: Step 1: Encouraging the client and family to be active partners promotes safety by involving them in care decisions.
Step 2: This empowers the client to voice concerns and preferences, enhancing their safety.
Step 3: Monitoring hand hygiene (B) is important but doesn't directly involve the client's active participation.
Step 4: Offering family to stay (C) is supportive but doesn't directly engage the client in promoting their own safety.
Step 5: Advising to wear armband (D) is a procedural measure, not a collaborative safety-promoting action.
The client with a chest tube after a coronary artery bypass graft has significantly slowed drainage. What action is most important for the nurse to take?
- A. Increase the setting on the suction.
- B. Notify the provider immediately.
- C. Re-position the chest tube.
- D. Take the tubing apart to assess for clots.
Correct Answer: B
Rationale: The correct answer is B: Notify the provider immediately. This is the most important action because significantly slowed drainage in a client with a chest tube after surgery can indicate a potential complication like a blocked tube or bleeding. Notifying the provider allows for prompt assessment and intervention to prevent further complications.
Increasing the suction setting (choice A) without knowing the reason for slowed drainage can potentially worsen the situation. Re-positioning the chest tube (choice C) may not address the underlying issue causing the slowed drainage. Taking the tubing apart to assess for clots (choice D) should not be done by the nurse as it can introduce the risk of infection and requires sterile technique.
Which of the following are the treatments of a non-severe sty?
- A. Cold compresses
- B. Warm soaks
- C. Limited sensory stimulation
- D. Incision and drainage
Correct Answer: B
Rationale: Warm soaks help reduce inflammation and promote healing of a non-severe sty.
A healthcare professional is assessing a client who has a new onset of confusion. Which laboratory value should the professional check first?
- A. Blood glucose level
- B. Serum sodium level
- C. Serum calcium level
- D. Blood urea nitrogen (BUN)
Correct Answer: A
Rationale: The correct answer is A: Blood glucose level. The healthcare professional should check the blood glucose level first because hypoglycemia or hyperglycemia can cause confusion. Hypoglycemia can lead to altered mental status quickly and should be ruled out immediately. Checking the serum sodium level (B), serum calcium level (C), or blood urea nitrogen (D) can be important in further assessment, but addressing the blood glucose level is the primary concern in this scenario to rule out any immediate life-threatening conditions related to glucose imbalance.