Nokea
The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?
- A. Dizziness can occur during cleansing.
- B. Foreskin should not be retracted.
- C. An erection may occur while providing care.
- D. Pubic area should be kept shaved.
Correct Answer: B
Rationale: Non-retractable foreskin should not be forced to prevent discomfort.
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The mother of a child born with Tetralogy of Fallot asks the nurse, 'Why did this happen to my baby? What did I do wrong?' Which response by the nurse is most helpful?
- A. This must be a very difficult time for you.'
- B. You did nothing wrong.'
- C. With surgery, your baby should have a full recovery.'
- D. Is there any particular reason why you think this is your fault?'
Correct Answer: A
Rationale: Empathy supports emotional expression without judgment.
In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?
- A. Recommend asking the healthcare professional for a patient-controlled analgesia (PCA) pump.
- B. Explain the respiratory problems that can occur with morphine use.
- C. Teach family how to evaluate the effectiveness of analgesics.
- D. Provide client with a schedule of around-the-clock prescribed analgesic use.
Correct Answer: D
Rationale: Scheduled analgesics ensure consistent pain relief.
A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?
- A. Paper mask and gown.
- B. A sputum specimen.
- C. The nurse's stethoscope.
- D. Bed linens.
Correct Answer: A
Rationale: Contaminated mask and gown require biohazard disposal.
Which is the best approach for the nurse to use when interviewing a client about sexuality/reproductive function?
- A. Ask questions in a vague, nonspecific format.
- B. Get the most difficult questions over with first.
- C. Share personal values to put the client at ease.
- D. Begin with questions that are less sensitive in nature.
Correct Answer: D
Rationale: Less sensitive questions build rapport.
An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first?
- A. Consult the palliative care team about the client's care.
- B. Set up a family conference to discuss the client's wishes.
- C. Discuss with the client her meaning of heroic measures.
- D. Obtain a 'do not resuscitate' (DNR) prescription.
Correct Answer: C
Rationale: Clarifying 'heroic measures' ensures client wishes are understood.