Nokea
The nurse is caring for a group of clients on a surgical unit. Which client should the nurse assess first?
- A. A client who is two days post knee surgery and describes pain at a "4" on a 1 to 10 scale
- B. A client who is one day post bowel resection with no bowel sounds
- C. A client who is 8 hours post appendectomy with urinary output of 480 ml
- D. A client who was admitted with severe abdominal pain and suddenly has no pain
Correct Answer: D
Rationale: The correct answer is D. A sudden absence of pain in a client with severe abdominal pain may indicate a serious condition such as internal bleeding. This sudden change in pain status requires immediate assessment to rule out any life-threatening complications. Choices A, B, and C do not indicate an acute change in the client's condition that would necessitate immediate attention compared to sudden pain relief in a client with severe abdominal pain.
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A male client with hypercholesterolemia wants to change his diet to help reduce his cholesterol levels. Which breakfast items should the nurse encourage the client to eat? (Select all that apply)
- A. Sausage patties and eggs
- B. Whole wheat toast and jam
- C. Bagels and cream cheese
- D. Blackberries and oatmeal
Correct Answer: B
Rationale: The correct choices are whole wheat toast and jam (B) and blackberries and oatmeal (D). Whole wheat toast and blackberries are high in fiber, which can help lower cholesterol levels. Sausage patties and eggs (A) are high in saturated fats that can raise cholesterol levels. Bagels and cream cheese (C) are not as beneficial for cholesterol control compared to high-fiber options like whole wheat toast and blackberries.
A client with a severe prostatic infection that caused a blocked urethra is 3 days post-surgical urinary diversion. The healthcare provider directs the nurse to remove the suprapubic catheter to allow the client to void normally. Which intervention should the nurse implement first?
- A. Cleanse the site around the catheter
- B. Use a 20 ml syringe to deflate balloon
- C. Clamp catheter until the client voids naturally
- D. Empty urine from the urinary drainage bag
Correct Answer: B
Rationale: The correct answer is to use a 20 ml syringe to deflate the balloon first when removing a suprapubic catheter. This step is essential to ensure the safe removal of the catheter without causing any harm or discomfort to the client. Deflating the balloon allows for the catheter to be easily removed. Option A, cleansing the site around the catheter, is not the initial step in this process and can be done after catheter removal. Option C, clamping the catheter until the client voids naturally, is incorrect as it can lead to complications like urinary retention. Option D, emptying urine from the urinary drainage bag, is not the first step in removing the suprapubic catheter and does not address the need to deflate the balloon for safe removal.
Before administering an intramuscular injection, the nurse's finger is stuck with the needle. Which action should the nurse take?
- A. Go to the emergency room to have blood drawn
- B. Prepare the medication using a new syringe
- C. Apply clean gloves before giving the medication
- D. Review the medical history in the client's chart
Correct Answer: B
Rationale: In this scenario, if the nurse's finger is stuck with the needle before administering the injection, the correct action is to prepare the medication using a new syringe. This step is crucial to prevent contamination and ensure the safety of the patient. Going to the emergency room to have blood drawn is unnecessary and does not address the immediate issue of contamination. Applying clean gloves is important for infection control but does not address the potential contamination from the needlestick. Reviewing the medical history in the client's chart is important for overall patient care but is not the priority in this situation where immediate action is required to prevent harm.
The nurse notes that a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?
- A. Encourage the client's family to visit more often
- B. Schedule a daily conference with the social worker
- C. Encourage the client to participate in group activities
- D. Engage the client in a non-threatening conversation
Correct Answer: D
Rationale: Engaging the client in a non-threatening conversation is crucial as it can help build trust and provide support, addressing the client's withdrawal. This intervention focuses on establishing a therapeutic relationship and giving the client an opportunity to express their feelings. Choices A, B, and C do not directly target the client's need for communication and may not address the underlying issues contributing to her withdrawal. Encouraging the client's family to visit more often (Choice A) may add pressure or discomfort to the client. Scheduling a daily conference with the social worker (Choice B) may not address the client's immediate need for communication. Encouraging the client to participate in group activities (Choice C) may be overwhelming for the client and not address her withdrawal directly.
A client with active tuberculosis (TB) is receiving isoniazid (INH) and rifampin (RMP) daily, so direct observation therapy (DOT) is initiated while the client is hospitalized. Which instruction should the nurse provide this client?
- A. Describe feelings about taking daily medications
- B. Take medications in the presence of the nurse
- C. Notify the nurse after self-medication is completed
- D. Keep a daily record of all medications taken
Correct Answer: B
Rationale: The correct instruction for the nurse to provide the client undergoing direct observation therapy for TB is to take medications in the presence of the nurse. This approach ensures that the client is actually taking the medications as prescribed, reducing the risk of noncompliance. Choice A is incorrect because the focus should be on ensuring the client physically takes the medications rather than discussing feelings. Choice C is incorrect as it does not ensure direct observation. Choice D is incorrect because self-reporting or keeping a record does not guarantee that the client is actually taking the medications.