Nokea
The nurse is caring for a client on strict bed rest. Which intervention is the priority when caring for this client?
- A. Encourage the client to drink liquids
- B. Perform active range of motion exercises
- C. Elevate the head of the bed to 45 degrees
- D. Provide a high-fiber diet to the client
Correct Answer: B
Rationale: Performing active range of motion exercises is the priority intervention for a client on strict bed rest. These exercises help prevent complications such as thromboembolism and muscle atrophy by promoting circulation and maintaining muscle strength. Encouraging liquids, elevating the head of the bed, and providing a high-fiber diet are important interventions but not the priority when compared to preventing serious complications associated with immobility.
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Which nursing action(s) can result in disciplinary action by state boards of nursing?
- A. Release of client health information to a client's neighbor
- B. Delegation of a dressing change to unlicensed assistive personnel (UAP)
- C. Release of client health information to the client's durable power of attorney
- D. A, B
Correct Answer: D
Rationale: The correct answer is D. Disclosing client health information to unauthorized individuals, such as a client's neighbor (choice A) or improper delegation of nursing tasks to unlicensed personnel like UAPs (choice B), are violations of patient confidentiality and safety. Releasing client health information to the client's durable power of attorney (choice C) is a legal and appropriate action, not warranting disciplinary action. Therefore, choices A and B can result in disciplinary action by state boards of nursing, making option D the correct answer.
The nurse is caring for the client one (1) day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?
- A. Change the infusion rate of the intravenous fluid
- B. Encourage the client to discuss his or her feelings
- C. Administer opioid narcotic medications for pain management
- D. Assist the client out of bed to sit in the chair twice daily
Correct Answer: D
Rationale: Assisting the client to sit in a chair is a crucial nursing intervention postoperatively. It helps prevent complications such as thrombosis, pneumonia, and pressure ulcers by promoting circulation and aiding in recovery. Changing the infusion rate of the intravenous fluid would require a physician's order and is not within the nurse's independent scope of practice. Encouraging the client to discuss feelings and administering medications for pain management are important interventions but may not be as immediately necessary as assisting the client in mobilizing early postoperatively.
The client has failed to conceive after many attempts over a three-year time period and asks the nurse, "I have tried everything. What should I do now?" Which statement is the nurse's best response?
- A. Assess the intravenous fluids for rate and volume
- B. Change the surgical dressing every day at the same time
- C. Monitor the client's medication levels daily
- D. Monitor the percentage of each meal eaten
Correct Answer: A
Rationale: The correct response is to assess the intravenous fluids for rate and volume. In this situation, the client is seeking guidance on fertility issues, not related to intravenous fluids, surgical dressing changes, medication levels, or meal monitoring. The nurse should provide supportive and empathetic guidance, suggesting further options like consulting fertility specialists or exploring additional treatments.
What is the combat health support system in the field designed to do?
- A. Provide evacuation to the far rear for treatment and delay return to duty
- B. Project, sustain, and protect the health of the soldier in war and operations other than war
- C. Provide rearward evacuation and reassignment
- D. Provide far rear area care and delayed return to duty
Correct Answer: B
Rationale: The correct answer is B. The combat health support system in the field is designed to project, sustain, and protect the health of soldiers in both war and operations other than war. Choice A is incorrect because the system is not primarily focused on providing evacuation to the far rear for treatment, but rather on overall health support. Choice C is incorrect as it only mentions rearward evacuation and reassignment, which is a limited scope compared to the comprehensive support provided by the system. Choice D is incorrect as it narrowly focuses on far rear area care and delayed return to duty, missing the broader aspects of health support and protection.
When is aspirin most effective when taken?
- A. On an empty stomach with cold water
- B. On a full stomach after a meal
- C. With a glass of fruit juice
- D. First thing in the morning
Correct Answer: A
Rationale: Aspirin is best absorbed on an empty stomach to maximize its effectiveness. Taking it with cold water helps in its quick absorption. Option B is incorrect because taking aspirin on a full stomach can delay its absorption. Option C is incorrect as fruit juice may not provide the ideal conditions for absorption. Option D is incorrect as taking aspirin first thing in the morning may not ensure an empty stomach.