Nokea
The home health nurse visits a client with heart failure who has increased dyspnea and peripheral edema and weight gain. The nurse suspects the client is not restricting fluids as prescribed. Which action by the nurse is most appropriate?
- A. Teach the client about the consequences of not following the fluid restrictions.
- B. Ask the client to report the amount of fluid intake for the past 24 hours.
- C. Provide the client with sugarless candy or gum to decrease the thirst sensation.
- D. Consult with the healthcare provider about increasing the dose of the diuretic.
Correct Answer: B
Rationale: The most appropriate action for the nurse is to ask the client to report the amount of fluid intake for the past 24 hours. This is the correct answer because it directly addresses the issue of non-compliance with fluid restrictions. By assessing the actual fluid intake, the nurse can identify the extent of the problem and provide targeted interventions.
Option A is not the best choice as teaching about consequences may not address the immediate issue. Option C does not address the root cause of the problem but only provides a temporary solution. Option D is not appropriate as increasing the diuretic dose should be done in collaboration with the healthcare provider after assessing the client's current condition.
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A nurse openly and genuinely discusses thoughts and feelings about sexually transmitted infections with a group of college students. Which benefit(s) may occur for these college students? (Select all that apply)
- A. The college students are reluctant to continue discussions with the nurse.
- B. The college students develop a trusting relationship with the nurse.
- C. The college students question the nurse's credibility.
- D. The college students believe the information is reliable and accurate.
Correct Answer: B
Rationale: The correct answer is B because openly discussing thoughts and feelings about sexually transmitted infections can help build trust between the nurse and college students. This trust can lead to the students feeling more comfortable seeking information and support from the nurse. Choice A is incorrect because open communication typically fosters ongoing discussions, not reluctance. Choice C is incorrect because open discussions can enhance credibility by showing transparency and expertise. Choice D is incorrect because open dialogue does not guarantee the accuracy of information, but it can facilitate a more informed discussion.
Ms. C (bowel resection and colostomy) is receiving epoetin alfa. Which laboratory test will the nurse check to see if the medication should be discontinued?
- A. Hemoglobin
- B. White cell count
- C. Potassium level
- D. Blood glucose level
Correct Answer: A
Rationale: The correct answer is A: Hemoglobin. Epoetin alfa is a medication that stimulates red blood cell production. Monitoring hemoglobin levels is crucial to assess the effectiveness of the medication. If hemoglobin levels rise too high, it can lead to complications like blood clots. Checking hemoglobin levels helps determine if the dose of epoetin alfa should be adjusted or discontinued.
Summary:
B: White cell count - Monitoring white cell count is not directly related to epoetin alfa therapy.
C: Potassium level - Monitoring potassium level is important for other medications like diuretics or ACE inhibitors, not specifically for epoetin alfa.
D: Blood glucose level - Monitoring blood glucose level is important for diabetic patients but not directly related to epoetin alfa therapy.
To convey the intervention of active listening, the nurse would:
- A. maintain eye contact by staring at the patient.
- B. prompt the patient when the patient stops talking for a moment.
- C. make a conscious effort to block out other sounds in the immediate environment.
- D. write down remarks on a clipboard to facilitate later topics of conversation. An active listener maintains eye contact without staring, gives the patient full attention, and makes a conscious effort to block out other sounds and distractions.
Correct Answer: C
Rationale: The correct answer is C because active listening involves making a conscious effort to block out other sounds in the immediate environment, demonstrating full focus on the speaker. This allows the nurse to truly understand the patient's perspective and feelings. Maintaining eye contact (A) is important but staring can be intimidating. Prompting the patient (B) may disrupt their train of thought. Writing down remarks (D) can be perceived as disengagement. In summary, active listening requires focused attention and empathy, which choice C exemplifies.
The nurse cares for a patient who complains of back pain. Which question should the nurse ask to obtain specific information about the back pain?
- A. "Would you like medication for the pain?"
- B. "What have you been doing in the last few days?"
- C. "Do you have a family history of osteoporosis?"
- D. "What do you think caused the back pain?"
Correct Answer: D
Rationale: The correct answer is D because asking "What do you think caused the back pain?" allows the patient to provide specific details about the onset and potential triggers of the pain, aiding in diagnosis and treatment planning. Choice A is incorrect as it focuses on medication rather than gathering information. Choice B is too broad and may not directly address the back pain issue. Choice C is irrelevant to the immediate assessment of the back pain and does not provide specific information about the patient's current condition.
Behaviors that indicate to the patient that the nurse is inattentive to the patient's concerns are such activities as: (Select all that apply.)
- A. turning back to straighten the bedside table while the patient is talking.
- B. tapping feet or fingers.
- C. sitting down in a chair near the bed with arms crossed.
- D. leaving a hand on the door to go out.
Correct Answer: A
Rationale: The correct answer, A, is turning back to straighten the bedside table while the patient is talking. This behavior indicates the nurse is not fully engaged in the conversation and prioritizing a task over the patient. Tapping feet or fingers (B) could just be a habit and may not necessarily indicate inattentiveness. Sitting down with arms crossed (C) could be a sign of being defensive but not necessarily inattentive. Leaving a hand on the door (D) could be a signal of readiness to leave but not a direct indicator of inattentiveness.