Nokea
The healthcare provider is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. Which term will the healthcare provider use when reporting to the oncoming shift?
- A. Cheilitis
- B. Halitosis
- C. Glossitis
- D. Dental caries
Correct Answer: B
Rationale: The correct term the healthcare provider will use when reporting the extremely bad breath of the unconscious patient to the oncoming shift is 'Halitosis' (Choice B). Halitosis specifically refers to bad breath. Cheilitis (Choice A) is inflammation of the lips, not related to bad breath. Glossitis (Choice C) is inflammation of the tongue, not directly associated with bad breath. Dental caries (Choice D) are cavities in the teeth, which can contribute to bad breath but are not the term used to describe bad breath itself.
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A 10-year-old client is recovering from a splenectomy following a traumatic injury. The client's laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to:
- A. Limit milk and milk products
- B. Encourage bed rest and quiet activities
- C. Plan nursing care around lengthy rest periods
- D. Promote a diet rich in iron
Correct Answer: C
Rationale: Encouraging bed rest and quiet activities is crucial for a child recovering from a splenectomy with low hemoglobin and hematocrit levels. This approach helps conserve energy, promotes healing, and allows the body to focus on rebuilding red blood cells. Limiting milk and milk products (Choice A) is not directly related to improving the child's condition. Encouraging bed rest and quiet activities (Choice B) is appropriate as it helps in conserving energy and preventing physical exertion. Promoting a diet rich in iron (Choice D) is beneficial for improving hemoglobin levels in the long term, but immediate rest and recovery take precedence in this scenario.
A client appears upset about the IV catheter insertion but does not communicate it to the nurse after being informed about the prescribed IV fluids. Which of the following is an appropriate nursing response?
- A. Ignore the client's discomfort
- B. Reassure the client without addressing concerns
- C. Is there something about this procedure that concerns you?
- D. Proceed with the procedure
Correct Answer: C
Rationale: The appropriate nursing response in this situation is to ask the client if there are any concerns about the procedure. By doing so, the nurse acknowledges the client's distress and opens up a dialogue to address any anxieties or misconceptions. Option A is incorrect as ignoring the client's discomfort can lead to increased anxiety and potential harm. Option B is not ideal as reassuring the client without addressing specific concerns may not alleviate the client's distress. Option D is incorrect because proceeding with the procedure without addressing the client's unspoken concerns can further escalate the client's distress.
A middle adult client tells the nurse, 'I feel so useless now that my children do not need me anymore.' Which of the following responses should the nurse make?
- A. People in middle adulthood often find satisfaction in nurturing and guiding young people.
- B. It's normal to feel this way; it will pass.
- C. You should focus on finding new activities to fill your time.
- D. Your children will always need you in some way.
Correct Answer: A
Rationale: The correct response is A. Middle adulthood is a stage where individuals often experience generativity, finding fulfillment in guiding and nurturing others. By acknowledging this aspect, the nurse can help the client explore opportunities to engage in activities that provide a sense of purpose and satisfaction. Choice A validates the client's feelings and offers a constructive way to address them. Choices B, C, and D do not address the client's emotional need for purpose and may not encourage the client to seek meaningful ways to address their feelings of uselessness.
A client who is postoperative has paralytic ileus. Which of the following abdominal assessments should the nurse expect?
- A. Absent bowel sounds with distention
- B. Hyperactive bowel sounds with pain
- C. Normal bowel sounds with cramping
- D. Diminished bowel sounds with tenderness
Correct Answer: A
Rationale: Paralytic ileus is a condition where there is a temporary paralysis of the bowel, leading to absent bowel sounds and abdominal distention. This occurs because the bowel is not functioning properly to propel contents, resulting in a lack of bowel sounds. Absent bowel sounds with distention are typical findings in paralytic ileus. Hyperactive bowel sounds with pain are more indicative of increased motility and are not expected in paralytic ileus. Normal bowel sounds with cramping may be seen in other conditions, such as gastroenteritis. Diminished bowel sounds with tenderness are not typical findings in paralytic ileus.
The healthcare professional prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The healthcare professional should regulate the IV to administer approximately how many drops per minute?
- A. 80
- B. 8
- C. 21
- D. 25
Correct Answer: C
Rationale: To calculate the drops per minute for the IV infusion, first determine the total drops to be infused over 8 hours. 1,000 ml to be infused over 8 hours means 125 ml per hour (1000 ml / 8 hours = 125 ml/hr). Since the infusion set delivers 10 drops per ml, 125 ml/hr x 10 drops/ml = 1250 drops/hr. To find drops per minute, divide the drops per hour by 60 (minutes in an hour): 1250 drops/hr / 60 minutes = 20.83 drops/minute, which rounds up to 21 drops per minute (Option C). This rate ensures the correct infusion rate over 8 hours. Choices A, B, and D are incorrect calculations and do not provide the appropriate infusion rate needed to administer the IV over the specified time period.