Nokea
The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next?
- A. Insert an oral airway.
- B. Place the patient in a flat, supine position.
- C. Use undiluted hydrogen peroxide as a cleaner.
- D. Quickly proceed without talking to the patient.
Correct Answer: A
Rationale: When a debilitated patient resists oral hygiene, the nurse should prioritize safety. Inserting an oral airway helps keep the mouth open, ensuring adequate access for oral care procedures while preventing any accidental biting or closure of the airway. Placing the patient in a flat, supine position may not address the resistance issue and can lead to aspiration risk. Using undiluted hydrogen peroxide is not recommended due to its potential harmful effects on oral tissues. Proceeding quickly without communication can escalate the situation and compromise patient-centered care.
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How should a healthcare professional care for a client approaching death with shortness of breath and noisy respirations?
- A. Turn the client every 2 hours
- B. Provide supplemental oxygen
- C. Use a fan to reduce the feeling of breathlessness
- D. Administer diuretics as prescribed
Correct Answer: C
Rationale: In a palliative care setting, when caring for a client approaching death with symptoms of shortness of breath and noisy respirations, using a fan can help alleviate the sensation of breathlessness. This intervention can provide comfort by improving air circulation and reducing the perception of breathlessness. Turning the client every 2 hours may not directly address the respiratory distress caused by noisy respirations. Providing supplemental oxygen may not be indicated or effective in all cases, especially in end-of-life care where the focus is on comfort rather than aggressive interventions. Administering diuretics as prescribed would not be appropriate for addressing noisy respirations and shortness of breath in a dying client, as this may not be related to fluid overload or congestion. Therefore, the most appropriate action to help the client feel more comfortable in this situation is to use a fan to reduce the feeling of breathlessness.
A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, what should the nurse do?
- A. Lock the wheels on the bed and gurney
- B. Adjust the bed height
- C. Use a slide sheet
- D. Ask for assistance from another nurse
Correct Answer: A
Rationale: The correct action for the nurse to take when transferring a postoperative client from the gurney to the bed is to lock the wheels on both the bed and the gurney. Locking the wheels ensures stability and prevents accidents during the transfer. Adjusting the bed height may be necessary for comfort but is not the primary concern during the transfer process. Using a slide sheet may be helpful in repositioning the client once on the bed but is not essential for the initial transfer. Asking for assistance from another nurse is always a good practice, but the immediate action to ensure safety during the transfer is to lock the wheels.
A client has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?
- A. Ensure the catheter tubing is free of kinks.
- B. Clean the perineal area with antiseptic solution daily.
- C. Irrigate the catheter with normal saline every shift.
- D. Secure the catheter to the client's leg.
Correct Answer: B
Rationale: Cleaning the perineal area with antiseptic solution daily is essential to prevent infection when caring for a client with an indwelling urinary catheter. This practice helps reduce the risk of introducing pathogens into the urinary tract. Ensuring the catheter tubing is free of kinks (Choice A) is important for maintaining proper urine flow but is not directly related to preventing infection. Irrigating the catheter with normal saline every shift (Choice C) is not a routine practice and can increase the risk of introducing pathogens. Securing the catheter to the client's leg (Choice D) is important for stability but does not directly prevent infection.
A client with heart failure is being taught by a nurse on reducing daily sodium intake. What is the most important factor in determining the client's ability to learn new dietary habits?
- A. The involvement of the client in planning the change
- B. The presence of a dietitian during the teaching
- C. The use of dietary supplements
- D. The client's family support
Correct Answer: A
Rationale: The most crucial factor in the client's ability to learn new dietary habits is their involvement in planning the change. When clients actively participate in setting their dietary goals, they are more likely to commit to and adhere to the changes. This empowerment fosters a sense of ownership and responsibility, enhancing the chances of successful dietary modifications. The presence of a dietitian, use of dietary supplements, and family support, while beneficial, are not as critical as the client's active participation in planning the dietary changes.
A client with type 1 diabetes mellitus is experiencing hypoglycemia. What is the best initial action for the LPN/LVN to take?
- A. Administer glucagon intramuscularly.
- B. Give the client 4 ounces of orange juice.
- C. Give the client a snack containing protein and carbohydrates.
- D. Encourage the client to rest until symptoms resolve.
Correct Answer: B
Rationale: The best initial action for a client with type 1 diabetes mellitus experiencing hypoglycemia is to give them 4 ounces of orange juice. Orange juice quickly raises blood glucose levels in a hypoglycemic client. Administering glucagon intramuscularly is not the best initial action for hypoglycemia; it is usually reserved for severe hypoglycemia cases. Giving a snack containing protein and carbohydrates is not as rapid as orange juice in raising blood glucose levels during hypoglycemia. Encouraging the client to rest until symptoms resolve does not address the immediate need to raise blood glucose levels in a hypoglycemic state.