Nokea
Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?
- A. Balance and coordination
- B. Cognitive status
- C. Level of pain
- D. Upper body muscle strength
Correct Answer: D
Rationale: The correct answer is D: Upper body muscle strength. The ability to use a trapeze bar requires adequate upper body strength to support the weight and facilitate repositioning. While assessing pain, coordination, and cognitive status are important, the priority is determining if the client can physically manage the trapeze bar safely. Without sufficient upper body muscle strength, the client may not be able to use the trapeze bar effectively and safely. Assessing balance and coordination is also important but secondary to ensuring the client has the required upper body strength. Cognitive status is crucial for understanding instructions related to using the trapeze bar, but it is not the most critical assessment in this scenario. Pain assessment is essential for overall care but does not directly impact the client's ability to use a trapeze bar like upper body muscle strength does.
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When assessing a client, why is it important for the nurse to be informed about cultural issues related to the client's background?
- A. Normal patterns of behavior may be labeled as deviant, immoral, or insane
- B. The meaning of the client's behavior can be derived from conventional wisdom
- C. Personal values will guide the interaction between individuals from different cultures
- D. The nurse should rely on her knowledge of different developmental mental stages
Correct Answer: A
Rationale: Being aware of cultural differences is crucial because normal behaviors in one culture may be perceived as deviant, immoral, or insane in another. This awareness helps the nurse avoid misunderstandings or misinterpretations of behaviors that are considered acceptable in the client's cultural context but may be viewed differently in another. Choices B, C, and D are incorrect because understanding cultural issues goes beyond deriving meanings from conventional wisdom, personal values guiding interactions, or relying solely on knowledge of developmental mental stages.
A client with hypertension is prescribed hydrochlorothiazide. What teaching should the nurse provide?
- A. Take the medication in the morning to avoid frequent urination at night.
- B. Increase fluid intake to prevent dehydration.
- C. Avoid potassium-rich foods, such as bananas and oranges.
- D. Monitor the client's potassium levels weekly.
Correct Answer: B
Rationale: The correct teaching for a client prescribed hydrochlorothiazide is to increase fluid intake to prevent dehydration. Hydrochlorothiazide is a diuretic that can lead to fluid loss and electrolyte imbalances, so adequate fluid intake is crucial. Choice A is incorrect because hydrochlorothiazide is typically taken in the morning to avoid nighttime urination. Choice C is incorrect as potassium-rich foods should not be avoided but monitored, as hydrochlorothiazide can cause potassium loss. Choice D is incorrect as potassium levels should be monitored regularly, but not necessarily weekly, unless indicated by the healthcare provider.
Which statement made by the client indicates an understanding of the instructions regarding the administration of alendronate (Fosamax)?
- A. I will take the medication at bedtime to avoid stomach upset.
- B. I will take the medication with a full glass of water first thing in the morning.
- C. I will lie down for 30 minutes after taking the medication.
- D. I will take the medication with food to reduce stomach irritation.
Correct Answer: B
Rationale: The correct answer is B. Alendronate (Fosamax) should be taken with a full glass of water in the morning to prevent esophageal irritation and ensure proper absorption. Choice A is incorrect because taking alendronate at bedtime increases the risk of esophageal irritation due to lying down. Choice C is incorrect because patients should remain upright for at least 30 minutes after taking alendronate to prevent esophageal irritation. Choice D is incorrect because alendronate should be taken on an empty stomach, not with food, to enhance absorption.
A client who has been prescribed multiple antihypertensive medications experiences syncope and has a blood pressure of 70/40. What is the rationale for the nurse to hold the next scheduled antihypertensive dose?
- A. Increased urinary clearance of the medications has produced diuresis, lowering the blood pressure.
- B. The antagonistic interaction of the medications has reduced their effectiveness.
- C. The synergistic effect of the medications has resulted in drug toxicity, causing hypotension.
- D. The additive effect of the medications has lowered the blood pressure too much.
Correct Answer: D
Rationale: The additive effect of multiple antihypertensive medications can cause hypotension, leading to dangerously low blood pressure. In this scenario, the client experiencing syncope with a blood pressure of 70/40 indicates severe hypotension, likely due to the combined action of the antihypertensive medications. Holding the next scheduled dose is essential to prevent further lowering of blood pressure and potential complications. Choices A, B, and C provide inaccurate explanations and do not align with the client's presentation and the need to manage hypotension caused by the additive effect of the medications.
The nurse is providing care for a client with a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse implement to prevent complications associated with the tube?
- A. Elevate the head of the bed to 15 degrees during feedings
- B. Aspirate gastric contents before administering medications
- C. Clamp the tube between feedings
- D. Flush the tube with water before and after feedings
Correct Answer: D
Rationale: Flushing the PEG tube with water before and after feedings helps prevent clogging and maintains tube patency. Proper flushing is essential for avoiding complications related to tube blockages. Elevating the head of the bed is important for preventing aspiration during and after feedings, not specifically related to PEG tube complications. Aspirating gastric contents before administering medications is not routinely recommended for PEG tube care. Clamping the tube between feedings can lead to tube occlusion and is not a standard practice in PEG tube care.