Nokea
The nurse is caring for clients in a rural health clinic and wants to promote illness prevention. Which action should the nurse take?
- A. Provide education about accident prevention
- B. Screen all clients for hypertension
- C. Refer clients with chronic conditions to a specialist
- D. Teach clients with diabetes about a diabetic diet
Correct Answer: A
Rationale: In a rural clinic, illness prevention primary prevention aims to stop disease before it starts, critical where access lags. Providing accident prevention education, like safe tractor use or fall risks, targets common rural hazards, reducing injuries proactively. Screening for hypertension is secondary, detecting issues, not preventing them. Referring chronic cases to specialists or teaching diabetic diets is tertiary, managing existing conditions, not averting onset. Accident prevention fits rural needs data shows higher injury rates in such areas empowering clients with knowledge to avoid harm. The nurse's action aligns with nursing's preventive role, addressing environmental and lifestyle risks unique to the setting, enhancing community health by tackling root causes before they escalate, a practical step given limited rural resources.
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When should discharge planning begin for a client admitted to a long-term care facility for rehabilitation after a total hip arthroplasty?
- A. One week prior to the client's discharge
- B. Upon the client's admission to the care facility
- C. Once the discharge date is identified
- D. When the client addresses the topic with the nurse
Correct Answer: B
Rationale: Discharge planning should begin upon the client's admission to the care facility. This early start allows the healthcare team to conduct assessments, set goals, and coordinate services for a smooth transition back home or to the community. Initiating discharge planning early ensures timely arrangements, leading to optimal outcomes and continuity of care. Choices A, C, and D are incorrect because waiting until one week before discharge, after the discharge date is identified, or until the client brings up the topic may lead to rushed decision-making, inadequate arrangements, and a less effective transition process.
Mr. Gary, at 67, is reflecting on his life achievements. This is an example of which Erikson's stage?
- A. Trust vs. Mistrust
- B. Industry vs. Inferiority
- C. Identity vs. Role confusion
- D. Integrity vs. Despair
Correct Answer: D
Rationale: At 67, reflecting on achievements is Integrity vs. Despair (D) Erikson's late adulthood, assessing life's worth. Trust (A) is infancy, industry (B) childhood, identity (C) adolescence not age-appropriate. D fits reflection, making it correct.
A nurse is caring for a client receiving high-flow oxygen therapy via a noninvasive positive pressure ventilation (NPPV) device. What is an important nursing intervention for this client?
- A. Assessing the client's oxygen saturation every 4 hours
- B. Monitoring the client's respiratory rate every 15 minutes
- C. Providing frequent oral care to prevent dry mouth
- D. Administering oxygen at a flow rate of 1-2 L/min
Correct Answer: C
Rationale: Providing frequent oral care (C) is key with NPPV (e.g., CPAP/BiPAP), as high-flow air dries the mouth, risking sores or discomfort. Q4h SpO2 (A) isn't specific to NPPV. Q15min RR (B) is excessive. 1-2 L/min (D) doesn't apply to NPPV. Oral care enhances comfort, per critical care standards, vital for compliance.
Miss Imelda asked you, What is WET TO DRY Dressing method? Your best response is
- A. It is a type of mechanical debridement using Wet dressing that is applied and left to dry to remove dead tissues
- B. It is a type of surgical debridement with the use of Wet dressing to remove the necrotic tissues
- C. It is a type of dressing where in, The wound is covered with Wet or Dry dressing to prevent contamination
- D. It is a type of dressing where in, A cellophane or plastic is placed on the wound over a wet dressing to stimulate healing of the wound in a wet medium
Correct Answer: A
Rationale: The wet-to-dry dressing method (A) is a mechanical debridement technique where a wet gauze is applied to a wound, then dries, adhering to and removing necrotic tissue when peeled off. Surgical debridement (B) involves cutting, not dressings. Option C misrepresents it as a protective dressing, ignoring debridement. Option D describes wet-to-moist dressings, not wet-to-dry. Wet-to-dry targets dead tissue removal, aiding healing in wounds like Imelda's, making A accurate and the best response.
A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?
- A. Elevate the head of the bed to 30°
- B. Flush the tube with 50 mL of water every 2 hours
- C. Replace the feeding bag and tubing every 72 hours
- D. Check the client's gastric residual every 8 hours
Correct Answer: A
Rationale: Elevating the head of the bed to 30° is the correct action to take when a client is receiving continuous enteral feedings through a nasogastric tube. This position helps prevent aspiration of the enteral feedings into the lungs, reducing the risk of aspiration pneumonia. Additionally, elevating the head of the bed promotes proper digestion and absorption of the feedings by utilizing gravity to facilitate movement into the stomach and through the gastrointestinal tract. Flushing the tube with water every 2 hours (Choice B) is not necessary for continuous feedings and may disrupt the feeding schedule. Replacing the feeding bag and tubing every 72 hours (Choice C) is not the standard recommendation unless there are specific concerns or complications. Checking the client's gastric residual every 8 hours (Choice D) is important but not the immediate action needed to prevent aspiration during enteral feedings.