Nokea
A nurse is contributing to the plan of care for a client who practices the Muslim faith. Which of the following actions should the nurse include in the plan?
- A. Serve foods that have a hot/cold balance.
- B. Serve milk products prior to meals
- C. Request a meal tray without pork.
- D. Remove tea and coffee from meal trays.
Correct Answer: C
Rationale: Muslim dietary laws prohibit pork, so meals should be planned accordingly.
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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 nurse is planning care for a new client. Which of the following actions should the nurse plan to take in order to use the technique of presence to establish the nurse-client relationship?
- A. Telephones the client at his home prior to admission to make an introduction.
- B. Dominate the conversation to reduce the client's anxiety.
- C. Share stories about personal experiences with the client.
- D. Use active listening when with the client.
Correct Answer: D
Rationale: Using active listening helps establish presence by showing genuine interest and attention to the client.
A nurse is caring for a client who is postoperative. The nurse should recognize that which of the following methods is the most reliable source when determining the intensity of the client's pain?
- A. Vital sign measurement
- B. Client's self-report of pain
- C. Visual observation for nonverbal signs of pain
- D. Nature of invasiveness of the surgical procedure
Correct Answer: B
Rationale: The correct answer is B: Client's self-report of pain. This is the most reliable source for determining the intensity of the client's pain because pain is a subjective experience and can vary greatly among individuals. The client is the best source to accurately describe their pain level, location, and quality. Vital sign measurements (A) may provide some indication of pain, but they are not as accurate as the client's self-report. Visual observation (C) may be helpful, but it can be subjective and may not always correlate with the client's actual pain level. The nature of invasiveness of the surgical procedure (D) may give some indication of potential pain level, but it does not directly measure the client's current pain intensity.
A nurse is caring for a client who had a severe traumatic brain injury 3 weeks ago, remains unconscious, and is unlikely to recover. While bathing the client, the assistive personnel (AP) talks to him about current events. The client's partner asks the nurse why the AP talks to the client. Which of the following responses should the nurse make?
- A. I'm really not sure why the assistant is talking to him. Perhaps you should ask her.
- B. Although your partner is not responding to us, he might still be able to hear.
- C. Don't let that concern you. She talks to all her clients, no matter what.
- D. She is an excellent caregiver. She has many others to care for, but she takes the time to talk to your partner.
Correct Answer: B
Rationale: The correct answer is B because even though the client is unconscious, research has shown that individuals in such states may still have some level of awareness. Talking to the client can provide comfort, stimulate brain activity, and maintain a sense of connection. Choices A, C, and D are incorrect because they do not address the potential benefits of talking to the unconscious client. A deflects the question, C dismisses the partner's concern, and D praises the AP but does not explain the rationale behind talking to the client.
A nurse is collecting data about a client's pulmonary system. While auscultating the client's lungs, the nurse hears continuous gurgling, low-pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?
- A. Rhonchi
- B. Crackles
- C. Wheezing
- D. Friction rub
Correct Answer: A
Rationale: The correct answer is A: Rhonchi. Rhonchi are continuous, low-pitched gurgling sounds heard over the trachea and bronchi. This finding indicates the presence of secretions or mucus in the larger airways. Crackles (B) are discontinuous, popping sounds heard during inspiration and indicate fluid in the alveoli. Wheezing (C) is a high-pitched whistling sound that occurs when air flows through narrowed airways. Friction rub (D) is a grating or rubbing sound heard during inspiration and expiration, caused by inflammation of the pleural surfaces. The other choices are not consistent with the described findings.