Nokea
A nurse is developing a therapeutic relationship with a client. The nurse should perform which of the following actions during the working phase of a therapeutic relationship?
- A. Determine the reason the client sought care.
- B. Instruct the client about methods to achieve goals.
- C. Discuss the client's new skill sets.
- D. Review the client's demographic information.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client about methods to achieve goals. During the working phase of a therapeutic relationship, the nurse focuses on helping the client achieve their goals through guidance, education, and collaboration. Instructing the client about methods to achieve goals empowers them to actively participate in their care and progress towards wellness. This action promotes client autonomy and self-efficacy, key components of a therapeutic relationship.
Incorrect choices:
A: Determining the reason the client sought care is typically done in the initial phase of the relationship.
C: Discussing the client's new skill sets may be more appropriate in the termination phase where progress is reviewed.
D: Reviewing the client's demographic information is necessary but not a primary action during the working phase.
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A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
- A. Count the apical pulsations for a full minute.
- B. Check the apical pulse with a Doppler device.
- C. Use the diaphragm of the stethoscope to listen to the apical pulsations.
- D. Press the stethoscope firmly against the client's skin.
Correct Answer: A
Rationale: The correct answer is A: Count the apical pulsations for a full minute. This is because counting the apical pulse for a full minute provides the most accurate assessment of the client's heart rate. It allows for any irregularities or fluctuations in the pulse to be detected.
Choice B is incorrect as using a Doppler device is not necessary for routine assessment of the apical pulse. Choice C is incorrect as the bell of the stethoscope, not the diaphragm, should be used to listen to the apical pulsations for better sound transmission. Choice D is incorrect as pressing the stethoscope firmly against the client's skin can create artifact noise and interfere with accurate auscultation.
A nurse is reinforcing teaching with a client who has diabetes mellitus about using a glucometer to monitor her blood glucose. Which of the following actions should the nurse identify as an indication that the client understands the instructions?
- A. Uses the ball of a finger as the puncture site
- B. Uses the side of a fingertip as the puncture site
- C. Avoids using the fingers of her dominant hand as puncture sites.
- D. Avoids using the thumbs as puncture sites
Correct Answer: B
Rationale: The correct answer is B: Uses the side of a fingertip as the puncture site. This is because the side of the fingertip has fewer nerve endings compared to the center, making it less painful for blood glucose monitoring. Choice A is incorrect as using the ball of a finger can be more painful. Choices C and D are incorrect as there is no specific reason to avoid using the fingers of the dominant hand or thumbs as puncture sites. It is important to choose a less painful site for blood glucose monitoring to encourage the client to monitor regularly.
A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take to help prevent an incisional infection?
- A. Initiate protective isolation.
- B. Allow the wound to air periodically.
- C. Clean the incision with soap and water.
- D. Perform hand hygiene prior to dressing changes.
Correct Answer: D
Rationale: The correct answer is D: Perform hand hygiene prior to dressing changes. This is important to prevent introducing harmful bacteria to the surgical wound, reducing the risk of infection. Hand hygiene is a crucial infection control measure as it helps to minimize the transfer of microorganisms. Initiating protective isolation (A) is not necessary for preventing incisional infections. Allowing the wound to air periodically (B) can actually increase the risk of contamination. Cleaning the incision with soap and water (C) may not be appropriate as it can irritate the wound and disrupt the healing process.
A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?
- A. Put on sterile gloves.
- B. Assist the client to the left Sims' position.
- C. Hang the enema container 61 cm (24 in) above the anus.
- D. Insert the tubing about 15 cm (6 in) into the anus.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to the left Sims' position. This position helps to facilitate the flow of the enema solution into the colon by allowing gravity to assist in the process. Placing the client in the left Sims' position helps to ensure proper administration and effectiveness of the enema.
A: Putting on sterile gloves is not necessary for administering a soapsuds enema.
C: Hanging the enema container 61 cm above the anus is not a standard practice for administering a soapsuds enema.
D: Inserting the tubing about 15 cm into the anus is too shallow and may not reach the desired area for the enema to be effective.
A 46-year-old African-American man is in an outpatient clinic for a physical examination. His BP is 126/84 mm Hg, his BMI is 24, and he reports no previous medical problems. Which of the following actions should the nurse take?
- A. Schedule his next appointment for 1 year from now.
- B. Provide information about how to reduce risk factors of hypertension.
- C. Schedule an appointment for a prostate-specific antigen (PSA) test.
- D. Provide information for a weight loss plan that includes increasing physical activity.
Correct Answer: B
Rationale: The correct answer is B: Provide information about how to reduce risk factors of hypertension. This is the appropriate action because the patient, being African-American, is at increased risk for hypertension. Providing information on lifestyle modifications such as a healthy diet, regular exercise, and stress management can help prevent the development of hypertension. This proactive approach aligns with preventative care and promotes the patient's overall well-being.
Choice A is incorrect because annual appointments may not address potential risk factors for hypertension. Choice C, scheduling a PSA test, is not relevant to the patient's current health assessment. Choice D, providing a weight loss plan, may be beneficial but not directly related to hypertension risk reduction in this scenario.