Nokea
The doctor orders a midstream urine specimen for your client who is an alert, oriented and ambulatory female client. What element should you include in your instructions to this client on the proper manner to collect this specimen?
- A. The need to cleanse the perineal area with circular wipes.
- B. The need to cleanse the perineal area from the 'dirtiest' to the 'cleanest'.
- C. The need to use a new antiseptic wipe for each wipe from the inner to the outer labia.
- D. The need to use a new antiseptic wipe for each wipe from the outer to the inner labia.
Correct Answer: C
Rationale: For a midstream urine specimen, the perineal area should be cleansed from front to back (inner to outer labia) using a new antiseptic wipe for each stroke to prevent contamination.
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The nurse is caring for a client who has just undergone a cholecystectomy. Which of the following positions is most appropriate for this client in the immediate postoperative period?
- A. Supine with the head of the bed flat.
- B. Semi-Fowler's position.
- C. Left lateral position.
- D. Prone position.
Correct Answer: B
Rationale: Semi-Fowler's position promotes lung expansion and reduces pressure on the surgical site after cholecystectomy.
The nurse is assessing a client with a suspected pulmonary embolism. Which of the following symptoms is most likely to be present?
- A. Bradycardia.
- B. Sudden chest pain.
- C. Hypotension.
- D. Fever.
Correct Answer: B
Rationale: Sudden chest pain is a common symptom of pulmonary embolism due to impaired blood flow to the lungs.
A mother calls the clinic after her 4-year-old choked on a peanut. The mother reports that she performed abdominal thrusts and the child is breathing normally now. The nurse should tell the mother to:
- A. Bring the child to the emergency department to check for airway obstruction.
- B. Test the child's urine for blood from internal bleeding.
- C. Call the physician if the child begins to sweat and feels dizzy.
- D. Observe the child for difficulty breathing because the abdominal thrusts may have caused a pneumothorax.
Correct Answer: C
Rationale: After choking, monitoring for symptoms like sweating or dizziness is crucial, as they may indicate complications like aspiration or trauma requiring medical attention.
Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply.
- A. Accepting the client while not arguing with the delusion.
- B. Focusing on the feelings or meaning of the delusion.
- C. Focusing on events and topics based in reality.
- D. Confronting the client's beliefs.
- E. Interacting with the client only when he is based in reality.
Correct Answer: A,B,C
Rationale: To manage grandiose delusions, the nurse should accept the client without reinforcing the delusion, focus on the underlying feelings, and redirect to reality-based topics. Confronting beliefs or limiting interaction to reality-based moments can escalate agitation or alienate the client.
You have been conducting a weekly outpatient stress management educational series for clients in the community who are hypertensive. The best way to evaluate the effectiveness of this educational series is to:
- A. Collect baseline blood pressure readings prior to the beginning of this educational series and then collect and compare blood pressure data during the series and after the series is completed.
- B. Collect baseline blood pressure readings prior to the beginning of this educational series and then collect and compare blood pressure data after the series is completed.
- C. Ask the clients how often they use the stress management techniques that they have learned during this educational series.
- D. Use a questionnaire at the end of the series that asks the participants how they liked the class and what they learned during this educational series.
Correct Answer: A
Rationale: Collecting and comparing blood pressure data before, during, and after the series provides objective evidence of the program's effectiveness in managing hypertension.