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A nurse is performing postmortem care for a recently deceased client prior to the client's family viewing. Which of the following actions should the nurse take?
- A. Cross the client's arms across their chest.
- B. Hold the client's eyes shut for a few seconds.
- C. Place the client in a high-Fowler's position.
- D. Remove the client's dentures from their mouth.
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is appropriate because it helps create a peaceful appearance for the deceased client, providing a more dignified and comforting view for the family during the viewing. Holding the eyes shut is a common practice to maintain a natural appearance and show respect for the deceased.
Crossing the client's arms (Choice A) is not necessary and may not be culturally appropriate for all families. Placing the client in a high-Fowler's position (Choice C) is not recommended as it may not be comfortable or appropriate for viewing. Removing the client's dentures (Choice D) is also unnecessary and may not be respectful to the deceased.
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A nurse is talking with an older adult client who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I'm not sure I want to retire.' Which of the following responses should the nurse make?
- A. You would have so much more time to spend with your family.'
- B. You should consider getting a part-time job or doing volunteer work.'
- C. Let's talk about how the change in your job status will affect you.'
- D. Why wouldn't you want to retire and relax?'
Correct Answer: C
Rationale: The correct response is C: "Let's talk about how the change in your job status will affect you." This response acknowledges the client's feelings and initiates a discussion about the potential impact of retirement on their well-being. It shows empathy and encourages open communication, allowing the nurse to explore the client's concerns and fears about retirement. This approach promotes client-centered care and helps the nurse understand the client's perspective better.
Choices A, B, and D are incorrect because they do not address the client's feelings or concerns directly. Option A assumes the client's main motivation for retirement is to spend time with family, which may not be the case. Option B and D provide suggestions without first understanding the client's thoughts and emotions, potentially dismissing their feelings. It is essential to prioritize the client's autonomy and individual needs in such discussions.
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
- A. Biofeedback
- B. Aloe
- C. Herbal remedies
- D. Acupuncture
Correct Answer: A
Rationale: The correct answer is A: Biofeedback. Biofeedback involves monitoring and controlling bodily functions to reduce pain and stress. In the case of herpes zoster, the skin lesions can be very sensitive, making it uncomfortable for the client to participate in biofeedback sessions. Additionally, the focus required for biofeedback may be challenging for someone experiencing pain from herpes zoster.
B: Aloe is a natural remedy that can be used topically to soothe skin irritations, including herpes zoster lesions. However, it may not provide adequate pain control.
C: Herbal remedies can be used to help manage pain in herpes zoster, such as capsaicin cream. While some herbal remedies may interact with medications, there is no general contraindication for their use in herpes zoster.
D: Acupuncture is a complementary therapy that involves inserting thin needles into specific points on the body to alleviate pain. It can be effective for pain relief in herpes zoster and is not contraindicated
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has epidural analgesia and weakness in the lower extremities.
- B. A client who has a hip fracture and a new onset of tachypnea.
- C. A client who has sinus arrhythmia and is receiving cardiac monitoring.
- D. A client who has diabetes mellitus and an HbA1C of 6.8%.
Correct Answer: B
Rationale: The correct answer is B because a client with a hip fracture and new onset of tachypnea may have a pulmonary embolism, a life-threatening complication that requires immediate assessment and intervention. Tachypnea can indicate hypoxia, which can be fatal if not addressed promptly. The nurse should prioritize assessing this client to ensure timely management and prevent further deterioration.
Clients A, C, and D do not present with immediate life-threatening conditions that require urgent assessment compared to client B. Client A's weakness in the lower extremities, client C's sinus arrhythmia, and client D's HbA1C level do not pose immediate risks to their health. Therefore, the nurse should assess client B first to address the potential pulmonary embolism.
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?
- A. Deep tendon reflexes 2+
- B. Pulse rate 100/min
- C. Urine output 20 mL/hr
- D. 1+ proteinuria via urine dipstick
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes 2+. Monitoring deep tendon reflexes is crucial when a client is receiving magnesium sulfate due to its potential to cause muscle weakness and CNS depression. The nurse should assess for hyperreflexia, which indicates magnesium toxicity. Choices B, C, and D are incorrect as they do not directly relate to the therapeutic effect of magnesium sulfate. Pulse rate and urine output may be affected by the medication but are not specific therapeutic effects to monitor for. Proteinuria can be a sign of kidney damage but is not a direct effect of magnesium sulfate therapy.
The nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe? Select all that apply.
- A. Limit alcohol intake to 0 oz per day.
- B. Keep daily fat intake to less than 35%.
- C. Administer an anti-obesity medication.
- D. Administer an antihypertensive medication.
- E. Limit foods high in potassium.
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. A: Limiting alcohol intake helps manage conditions like hypertension. B: Keeping fat intake below 35% helps prevent heart disease. D: Administering antihypertensive medication is essential for managing high blood pressure. C: Administering anti-obesity medication may not be necessary if the client's weight is not the primary concern. E: Limiting foods high in potassium is not necessary unless the client has specific medical conditions requiring it. Therefore, choices C and E are incorrect as they are not the priorities for the client's care in this scenario.