Nokea
The nurse is conducting walking rounds and observes the client (see figure). The nurse should do which of the following?
- A. Loosen the bed restraints so the client can sit up.
- B. Raise the side rails to full upright position.
- C. Assess the client to determine why she wants to sit up.
- D. Elevate the head of the bed.
Correct Answer: B
Rationale: Raising the side rails ensures client safety, preventing falls, especially if the client is attempting to sit up.
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When giving a client a tube feeding the nurse should:
- A. Warm the feeding solution before administration.
- B. Place the client in a left side-lying position.
- C. Aspirate residual gastric contents before the feeding and discard.
- D. Verify position of the tube before beginning feeding.
Correct Answer: D
Rationale: Verifying tube position (e.g., via pH testing or X-ray) is critical to ensure safe administration and prevent aspiration.
The nurse is evaluating a diabetic client's understanding of the signs of hyperglycemia. Which statement by the client reflects an understanding?
- A. I may become diaphoretic and faint.
- B. I may notice signs of fatigue, dry skin, and increased urination.
- C. I need to take an extra diabetic pill if my blood glucose is greater than 300.
- D. I should restrict my fluid intake if my blood glucose is greater than 250.
Correct Answer: B
Rationale: Fatigue, dry skin, polyuria, and polydipsia are classic symptoms of hyperglycemia. Fatigue occurs because of lack of energy from the inability of the body to use glucose. Dry skin occurs secondary to dehydration related to polyuria. Polydipsia occurs secondary to fluid loss. Diaphoresis is associated with hypoglycemia. A client should not take extra hypoglycemic agents to reduce an elevated blood glucose level. A client with hyperglycemia becomes dehydrated secondary to the osmotic effect of the elevated glucose; therefore, the client must increase fluid intake.
You are fully aware of the fact that some risk factors are correctable or modifiable and other risk factors are innate and not modifiable. Which of the following risk factors are most likely to be correctable?
- A. Genetic predisposition
- B. Lifestyle choices
- C. High risk behaviors
- D. An external locus of control
Correct Answer: B,C
Rationale: Lifestyle choices (e.g., diet, exercise) and high-risk behaviors (e.g., smoking, substance abuse) are modifiable risk factors that can be addressed through education and behavior change. Genetic predisposition and an external locus of control are less easily modified.
The nurse assesses a client with a diagnosis of rib fractures to identify the risk for potential complications. The nurse notes that the client has a history of emphysema. After the assessment, the nurse ensures that which interventions are documented in the plan of care? Select all that apply.
- A. Maintain the client in a position of comfort.
- B. Collect sputum specimens at the hour of sleep.
- C. Offer medication to suppress the cough as needed.
- D. Administer small, frequent meals with plenty of fluids.
- E. Have the client cough and breathe deeply 20 minutes after pain medication is given.
- F. Administer 4 to 6 liters of oxygen when the client's pulse oximetry drops below 90%.
Correct Answer: A,D,E
Rationale: Clients with a diagnosis of rib fractures need interventions focused on their ability to maintain an effective breathing pattern and support the body in the healing process. Breathing effort is supported when the client is maintained in a comfortable position. Giving the client small frequent meals with plenty of fluids prevents the client from doing too much eating activity at one time and provides hydration to keep sputum liquefied for easier expectoration. Giving the client prescribed pain medication first and then having the client cough and deep breathe will encourage the client to complete these actions while limiting the amount of pain from doing them. If sputum specimen collection is prescribed, the specimen should be collected early in the morning upon the client's awakening. Clients with emphysema are not given cough suppressants because expectoration of sputum is essential to airway clearance. Giving the client with emphysema a high flow of oxygen could halt the hypoxic drive and cause apnea. A prescription is needed for changes in the oxygen flow.
A diabetic primigravid client at 38 weeks' gestation asks the nurse why she had a fetal acoustic stimulation during her last nonstress test. Which of the following should the nurse include as the rationale for this test?
- A. To listen to the fetal heart rate
- B. To startle and awaken the fetus
- C. To stimulate mild contractions
- D. To confirm amniotic fluid amount
Correct Answer: B
Rationale: Fetal acoustic stimulation is used to startle and awaken the fetus, prompting movement to assess fetal heart rate reactivity during a nonstress test. It does not directly measure heart rate, stimulate contractions, or assess amniotic fluid.