Nokea
The healthcare provider is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the healthcare provider include in the assessment?
- A. Provide an interpreter to convey the meaning of words and messages in translation
- B. Commend the client for her patience during a long wait in the admission process
- C. Arrange for the hospital chaplain to visit the client during her hospital stay
- D. Rely on cultural norms as the basis for providing healthcare for this client
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?
- A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows.
- B. Instruct the UAP not to wake the client under any circumstances during the night.
- C. Place a 'Do Not Disturb' sign on the door and change assessments from every 4 to every 8 hours.
- D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.
Correct Answer: A
Rationale: The best action for the nurse is to determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. By incorporating familiar bedtime rituals that do not compromise the client's safety, the nurse can help the client fall asleep faster and improve the overall quality of care provided to the client.
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next?
- A. Clamp the catheter and recheck it in 60 minutes.
- B. Pull the catheter back 3 inches and redirect it upward.
- C. Leave the catheter in place and reattempt with another catheter.
- D. Notify the healthcare provider of a possible obstruction.
Correct Answer: C
Rationale: In this scenario, if no urine is seen in the tubing after inserting the catheter, it is likely that the catheter is in the vagina rather than the bladder. Leaving the first catheter in place will help locate the meatus more easily when attempting the second catheterization. This approach ensures correct placement of the catheter in the bladder and minimizes the risk of causing unnecessary discomfort or trauma to the patient.
The healthcare professional retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN for severe pain. How many mL should the healthcare professional administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth)
- A. 0.8 mL
- B. 0.75 mL
- C. 0.7 mL
- D. 0.9 mL
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client, who is newly diagnosed with arteriosclerosis and is obese, is being educated by the nurse on reducing the risk of a heart attack or stroke. Which health promotion brochure should the nurse provide to this client?
- A. Monitoring Your Blood Pressure at Home
- B. Smoking Cessation as a Lifelong Commitment
- C. Decreasing Cholesterol Levels Through Diet
- D. Stress Management for a Healthier You
Correct Answer: C
Rationale: The most significant risk factor contributing to arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Therefore, the most crucial brochure for the nurse to provide to the client focuses on decreasing cholesterol levels through diet to help reduce the risk of heart attack or stroke.
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?
- A. Tell the UAP to use a larger cuff at the next scheduled assessment.
- B. Reassess the client's blood pressure using a larger cuff.
- C. Have the unit educator review this procedure with the UAPs.
- D. Teach the UAP the correct technique for assessing blood pressure.
Correct Answer: B
Rationale: The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the blood pressure with the correct size cuff (B) to obtain an accurate reading. Postponing reassessment (A) could lead to inaccurate results. While (C and D) are important actions for education and quality improvement, they are not as critical as obtaining an accurate blood pressure reading in this situation.