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A nurse is reinforcing teaching with an older adult client. Which of the following strategies should the nurse use?
- A. Incorporate teaching needs into one daily session.
- B. Emphasize visual and auditory teaching techniques.
- C. Minimize distractions by closing the door to the room.
- D. Begin with the most difficult learning tasks.
Correct Answer: B
Rationale: The correct answer is B: Emphasize visual and auditory teaching techniques. Older adults may have sensory impairments, so utilizing visual and auditory cues can enhance learning. Visual aids like charts and diagrams, along with verbal explanations, can cater to different learning styles. This approach promotes better retention and understanding.
Incorrect options: A: Incorporating teaching needs into one daily session may overwhelm the older adult. C: Closing the door may create a sense of isolation. D: Beginning with the most difficult tasks can be discouraging and hinder learning progress.
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A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?
- A. High BP and low pulse rate
- B. Low BP and low pulse rate
- C. High BP and high pulse rate
- D. Low BP and high pulse rate
Correct Answer: D
Rationale: Hypovolemic shock leads to decreased blood pressure due to fluid loss and compensatory tachycardia.
A nurse is caring for a client whose partner asks to speak with the nurse. The client's partner relates that she is concerned because her partner abuses alcohol and has difficulty maintaining employment. Which of the following responses should the nurse make?
- A. If I were you, I would contact a support group.
- B. I'm so sorry to hear about this.
- C. I suggest you talk with the hospital chaplain about your concern.
- D. What have you done in the past to cope with this issue?
Correct Answer: D
Rationale: Exploring the partner's past coping strategies encourages problem-solving and emotional support.
A newly licensed nurse has obtained a capillary glucose level from a client that produced inaccurate results and reports this to the charge nurse. Which of the following actions should the charge nurse take?
- A. Assign another nurse to be responsible for obtaining capillary glucose levels.
- B. Verify that the newly licensed nurse attended the staff education class about capillary glucose levels.
- C. Repeat the capillary glucose levels.
- D. Recheck the next scheduled capillary glucose level immediately following the nurse's.
Correct Answer: C
Rationale: The correct answer is C: Repeat the capillary glucose levels. This action should be taken to confirm the accuracy of the initial results. By repeating the test, the charge nurse can determine if the inaccuracy was due to a procedural error or if there is an issue with the equipment. This step ensures that the client receives proper care based on accurate information.
Assigning another nurse (choice A) does not address the root cause of the inaccurate results. Verifying attendance at an education class (choice B) is not as immediate or relevant as repeating the test. Rechecking the next scheduled level (choice D) without verifying the accuracy of the initial result may lead to continued inaccuracies in care.
A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?
- A. Wrap the blood pressure cuff snugly around the arm.
- B. Place the client's arm above the level of the heart.
- C. Check the instrument gauge to ensure the reading starts at zero.
- D. Center the cuff bladder over the brachial artery.
Correct Answer: B
Rationale: The correct answer is B because placing the client's arm above the level of the heart can result in an inaccurate blood pressure reading. Ideally, the arm should be at heart level to obtain an accurate measurement. A: Wrapping the cuff snugly ensures an accurate reading. C: Checking the gauge for zero ensures proper calibration. D: Centering the cuff bladder over the brachial artery is correct for accurate measurement. Overall, maintaining the arm at heart level is crucial to obtaining an accurate blood pressure reading.
A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?
- A. He is doing well, although he might be in the hospital for some time.
- B. He has an electrical burn. He is stable, and we will update you with any changes.
- C. He has an electrical burn, which caused coagulation of some tissues.
- D. He does not appear to have much damage and should be fine soon.
Correct Answer: B
Rationale: Providing factual and clear information about the client's condition maintains trust and transparency with the family.