Nokea
The nurse is administering a cleansing enema to a client the night before bowel surgery. When administering the enema, the client reports cramping and pain. Which of the following actions should the nurse take?
- A. Slowly raise the height of the solution container
- B. Tell the client that the process will not take much longer
- C. Temporarily stop instilling the solution, then resume at a slower rate
- D. Withdraw the tube approximately 2 cm and continue the instillation
Correct Answer: C
Rationale: Pausing and slowing the flow reduces cramping by allowing the bowel to adjust. Raising the container increases pressure, reassurance doesn't address pain, and withdrawing the tube is unnecessary.
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The nurse is preparing to change the wound dressing for a client who is receiving negative pressure wound therapy. Which of the following actions should the nurse take? Select all that apply.
- A. Administer pain medication 30 minutes before the procedure
- B. Apply skin protectant to intact skin surrounding the wound
- C. Cut the foam dressing to the shape and size of the wound
- D. Ensure that the prescribed negative-pressure setting is applied
- E. Verify that the occlusive film dressing is free of air leaks
Correct Answer: A,B,C,D,E
Rationale: All actions are correct: pain management , skin protection , proper foam sizing , correct pressure , and leak-free dressing ensure effective therapy.
The precepting nurse supervising a graduate practical nurse would need to intervene when the graduate nurse violates the Health Insurance Portability and Accountability Act with which action? Select all that apply.
- A. Accesses the medical record of a client not currently assigned, but previously cared for, to assess client improvement.
- B. Advises the client transport technician, 'This client has fragile bones due to cancer, so move the client very carefully.'
- C. Asks a client, 'When were you diagnosed with diabetes?' in a semi-private room with the privacy curtain in place between beds.
- D. Interprets the results of a client's diagnostic testing to the unit clerk
- E. Writes a client's last name and room number on a whiteboard hanging in the nurse's station on which scheduled procedures are logged
Correct Answer: A,D,E
Rationale: Accessing unassigned records , sharing results with a clerk , and writing names on a public whiteboard violate HIPAA. Sharing relevant care info and private questioning are permissible.
The home health nurse is reviewing current medications with a client who has hypertension. Which of the following statements by the client would require follow-up?
- A. I take omeprazole daily to prevent heartburn.
- B. I regularly take ibuprofen for chronic low back pain.
- C. I occasionally take docusate sodium for constipation.
- D. I take hydrochlorothiazide daily to lower my blood pressure.
Correct Answer: B
Rationale: Ibuprofen can reduce the efficacy of antihypertensives and cause fluid retention, worsening hypertension. Omeprazole , docusate , and hydrochlorothiazide are unlikely to interfere with hypertension management.
As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do?
- A. Ask the student: 'What did you forget to do?'
- B. Stop. Tell me why aspiration is needed.
- C. Loudly state: 'You forgot to aspirate.'
- D. Walk up and whisper in the student's ear 'Stop. Aspirate. Then inject.'
Correct Answer: D
Rationale: This action is a direct threat to the client if the medication enters into the blood stream instead of the muscle. The purpose of aspiration with IM injections is to prevent the injection of the drug directly into the blood stream.
The nurse is caring for a client recovering from a fracture. Which diet selection would be best for this client?
- A. Fried chicken, a loaded baked potato, and tea
- B. Dressed cheeseburger, French fries, and soda
- C. Tuna fish salad on sourdough bread, potato chips, and skim milk
- D. Broiled chicken, Mandarin orange salad, and milk
Correct Answer: D
Rationale: A diet rich in protein, calcium, and vitamins supports bone healing. Broiled chicken, Mandarin orange salad, and milk provide these nutrients. Options A, B, and C include less nutrient-dense foods like fried items or chips, making them less ideal.