Nokea
The nurse has been assigned to train the unlicensed nursing assistant about prioritizing care. Which client should the nurse instruct the unlicensed nursing assistant to see first?
- A. The client who needs both sequential compression devices removed
- B. The elderly woman who needs assistance ambulating to the bathroom
- C. The surgical client who needs help changing the gown after bathing
- D. The male client who needs the intravenous fluid discontinued
Correct Answer: A
Rationale: The correct answer is A because removing sequential compression devices could increase the risk of thromboembolism, making it the priority. Choice B involves assisting with ambulation, which can be done after addressing the urgent need of the client in choice A. Choice C and D involve non-urgent tasks compared to the potential risks associated with not removing sequential compression devices promptly.
You may also like to solve these questions
Which referral would be most appropriate for the client diagnosed with thoracic outlet syndrome?
- A. The physical therapist
- B. The thoracic surgeon
- C. The occupational therapist
- D. The social worker
Correct Answer: C
Rationale: The correct answer is C, the occupational therapist. An occupational therapist specializes in helping individuals with activities of daily living, ergonomic assessments, and adaptive techniques. In the case of thoracic outlet syndrome, an occupational therapist can provide exercises and adaptations to improve the client's function and alleviate symptoms. Choosing the physical therapist (choice A) may also be beneficial for rehabilitation exercises, but occupational therapists focus more on functional activities. Referring to a thoracic surgeon (choice B) would be more appropriate for surgical interventions rather than initial management. Referring to a social worker (choice D) may not directly address the physical symptoms and functional limitations associated with thoracic outlet syndrome.
During peacetime, most CONUS hospital military personnel are organized into what type of organization?
- A. DVA
- B. TOE
- C. TDA
- D. NDMS
Correct Answer: C
Rationale: During peacetime, most CONUS hospital military personnel are organized into a TDA (Table of Distribution and Allowances) type of organization. TDA defines the structure and personnel requirements of a unit. Choice A, DVA (Department of Veterans Affairs), is not the typical organizational structure for military hospital personnel. Choice B, TOE (Table of Organization and Equipment), refers to the organization and equipment of a unit, not the personnel organization. Choice D, NDMS (National Disaster Medical System), is a federal program that coordinates medical responses to disasters and emergencies, but it is not the primary organizational structure for military hospital personnel during peacetime.
In which situation(s) does the nurse act as a client advocate?
- A. Pulling the curtain around the client's bed while changing a dressing
- B. Contacting the health care provider to request a meeting for the client
- C. Ensuring access to medical information by appropriate personnel only
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because all the situations listed reflect aspects of client advocacy. Pulling the curtain around the client's bed while changing a dressing ensures privacy and dignity for the client, which is an essential part of advocacy. Contacting the health care provider to request a meeting for the client involves advocating for the client's needs and preferences. Ensuring access to medical information by appropriate personnel only is another way the nurse advocates for the client by safeguarding their confidentiality and promoting proper communication. Choices A, B, and C all demonstrate different aspects of advocacy, making option D the correct choice.
Interacting with the patient and their family to obtain subjective information is part of which of the following steps in determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct Answer: D
Rationale: The correct answer is D, Assessment. In the nursing process, assessment is the first step where nurses gather subjective and objective data to understand the patient's needs. Interacting with the patient and their family to obtain subjective information is crucial in this phase. Choice A, Evaluation, comes later in the process and involves judging the effectiveness of the care provided. Choice B, Planning, is where the nurse develops a plan of care based on the assessment findings. Choice C, Implementation, is the phase where the nursing care plan is put into action.
The client has been diagnosed with hemorrhoids. Which statement from the client indicates that further teaching is needed?
- A. "I should increase fruits, bran, and fluids in my diet."
- B. "I will use warm compresses and take sitz baths daily."
- C. "I must take a laxative every night and have a stool daily."
- D. "I can use an analgesic ointment or suppository for pain."
Correct Answer: C
Rationale: Choice C indicates the need for further teaching because regular use of laxatives can lead to dependence and is not recommended for hemorrhoids. Increased fiber intake and fluid consumption (Choice A) help prevent constipation, warm compresses and sitz baths (Choice B) provide relief, and using analgesic ointments or suppositories (Choice D) can help manage pain associated with hemorrhoids.