Nokea
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to assistive personnel (AP)?
- A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia
- B. Reinforcing teaching w/a client who is learning to walk using a quad cane
- C. Reapplying a condom catheter for a client who has urinary incontinence
- D. Applying a sterile dressing to a pressure ulcer
Correct Answer: C
Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely delegated to assistive personnel (AP). This task involves a straightforward procedure that does not require advanced nursing skills or critical thinking. The nurse can provide clear instructions and oversee the AP's performance.
Choice A is incorrect because feeding a client with aspiration pneumonia requires close monitoring by a nurse due to the risk of complications. Choice B is incorrect as reinforcing teaching for a client learning to walk with a quad cane involves assessing the client's understanding and progress, which is within the nurse's scope. Choice D is incorrect because applying a sterile dressing to a pressure ulcer requires sterile technique and assessment of wound healing, which should be done by a nurse.
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To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? Select all.
- A. Hold the cane on the right side
- B. Keep 2 points of support on the floor
- C. Place the cane 15 inches in front of the feet before advancing
- D. After advancing the cane, move the weaker leg forward
- E. Advance the stronger leg so that it aligns evenly with the cane
Correct Answer: A, B, D
Rationale: Correct Answer: A, B, D
Rationale:
A: Holding the cane on the right side provides support for the weaker left lower extremity, aiding balance.
B: Keeping 2 points of support on the floor enhances stability and reduces the risk of falls.
D: Moving the weaker leg forward after advancing the cane promotes weight-bearing on the stronger leg first, reducing strain on the injured limb.
Summary:
C: Placing the cane 15 inches in front of the feet before advancing is too far and may lead to overreaching.
E: Advancing the stronger leg to align with the cane may shift the body weight incorrectly, increasing the risk of injury.
A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the client asks why water is necessary after the formula drains, the nurse should respond:
- A. Water helps clear the tube so it doesn't get clogged.
- B. Flushing helps make sure the tube stays in place.
- C. This will help you get enough fluids.
- D. Adding water makes the formula less concentrated.
Correct Answer: A
Rationale: The correct answer is A: Water helps clear the tube so it doesn't get clogged. Water is necessary after enteral feeding to flush the feeding tube and prevent clogging, ensuring proper delivery of nutrition. Flushing with water also prevents residue buildup and maintains tube patency. This action helps prevent complications such as tube occlusion, which can lead to inadequate delivery of feedings or discomfort for the client. Options B, C, and D are incorrect because the primary reason for flushing the tube with water is to prevent clogging and maintain tube patency, not to secure the tube, provide fluids, or adjust formula concentration.
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all.
- A. Warm the enema prior to instillation
- B. Position the client on the left side with the right leg flexed forward
- C. Lubricate the rectal tube or nozzle
- D. Slowly insert the rectal tube about 2 inches
- E. Hang the enema container 24 inches above the client's anus
Correct Answer: A, B, C
Rationale: The correct steps for administering a cleansing enema are to warm the enema prior to instillation to prevent discomfort, position the client on the left side with the right leg flexed forward to facilitate the flow of the solution, and lubricate the rectal tube or nozzle to ease insertion. Warming the enema helps relax the colon, the left side position helps the solution flow toward the rectum, and lubrication minimizes discomfort and potential injury. Other choices are incorrect: slowly inserting the rectal tube 2 inches is too shallow, hanging the enema container 24 inches above the client's anus may be too high causing a rapid flow and potential injury.
A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 minutes. The nurse should set the infusion pump to deliver how many mL/hr?
Correct Answer: 400
Rationale: The correct answer is 400 mL/hr. To calculate the mL/hr rate, we first convert the 15 minutes to hours (15 minutes ÷ 60 minutes = 0.25 hours). Then, we divide the total volume (100 mL) by the time in hours (100 mL ÷ 0.25 hours = 400 mL/hr). This rate ensures the safe and accurate administration of 100 mL of LR over a 15-minute period. Other choices are incorrect because they do not accurately calculate the mL/hr rate based on the given parameters.
A nurse is preparing to administer digoxin (Lanoxin) to a client who states, 'I don't want to take that med. I do not want one more pill.' Which of the following responses by the nurse is appropriate in this situation?
- A. Your physician prescribed it for you, so you really should take it.
- B. Well, let's just get it over with quickly then.
- C. Okay, I'll just give you your other meds.
- D. Tell me your concerns with taking this med.
Correct Answer: D
Rationale: Correct Answer: D. Tell me your concerns with taking this med.
Rationale: This response demonstrates therapeutic communication by acknowledging the client's feelings and encourages them to express their concerns. It shows empathy and respect for the client's autonomy in decision-making. By understanding the client's reasons for not wanting to take the medication, the nurse can address any misconceptions, provide education, and potentially find alternative solutions. This approach fosters trust and collaboration between the nurse and the client.
Incorrect choices:
A: This response is dismissive of the client's feelings and does not address the underlying concerns.
B: This response does not address the client's reluctance and may come off as insensitive.
C: This response avoids the issue at hand and does not promote open communication.