Nokea
A nurse is reinforcing teaching to a newly licensed nurse about caring for a client who is a member of the Seventh-Day Adventist church. The nurse should include in the teaching that which of the following foods are restricted with this religion?
- A. Leavened bread
- B. Eggs
- C. Milk
- D. Caffeinated coffee
Correct Answer: D
Rationale: The correct answer is D: Caffeinated coffee. Seventh-Day Adventists typically avoid caffeine due to health beliefs. Coffee contains caffeine, which is considered a stimulant and is restricted. Leavened bread (A) is not specifically restricted. Eggs (B) and milk (C) are generally accepted. In summary, the other choices are incorrect because they are not specifically restricted by the Seventh-Day Adventist church.
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A newly licensed nurse has obtained a capillary glucose level from a client that produced inaccurate results and reports this to the charge nurse. Which of the following actions should the charge nurse take?
- A. Assign another nurse to be responsible for obtaining capillary glucose levels.
- B. Verify that the newly licensed nurse attended the staff education class about capillary glucose levels.
- C. Repeat the capillary glucose levels.
- D. Recheck the next scheduled capillary glucose level immediately following the nurse's.
Correct Answer: C
Rationale: The correct answer is C: Repeat the capillary glucose levels. This action should be taken to confirm the accuracy of the initial results. By repeating the test, the charge nurse can determine if the inaccuracy was due to a procedural error or if there is an issue with the equipment. This step ensures that the client receives proper care based on accurate information.
Assigning another nurse (choice A) does not address the root cause of the inaccurate results. Verifying attendance at an education class (choice B) is not as immediate or relevant as repeating the test. Rechecking the next scheduled level (choice D) without verifying the accuracy of the initial result may lead to continued inaccuracies in care.
A nurse is caring for a client who has a stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care?
- A. Apply a heat lamp twice a day
- B. Cleanse with 0.9% sodium chloride irrigation
- C. Cleanse with povidone-iodine solution
- D. Massage reddened areas during dressing changes
Correct Answer: B
Rationale: 0.9% sodium chloride irrigation is recommended for granulating tissue. Povidone-iodine is cytotoxic and should not be used. Heat lamps and massage can cause further tissue damage.
A nurse manager is talking with a nurse who was unable to sleep the previous night after participating in an unsuccessful client resuscitation. Which of the following responses should the nurse manager make?
- A. Tell me what your concerns are.'
- B. Maybe you should schedule an appointment with a psychiatrist.'
- C. It's hard at first, but you will get used to these things.'
- D. Don't worry. We all go through these feelings. They will pass.'
Correct Answer: A
Rationale: Encouraging the nurse to express concerns supports emotional well-being and prevents burnout.
A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?
- A. Position the client supine.
- B. Have the client bear down during removal.
- C. Cleanse the perineal area with an antiseptic.
- D. Deflate the balloon halfway and then pull out the catheter.
Correct Answer: A
Rationale: The correct answer is A: Position the client supine. This position allows for easier access to the urinary catheter and minimizes the risk of spillage or contamination. Supine position also provides better comfort and stability for the client during the catheter removal process.
Summary of other choices:
B: Having the client bear down during removal can increase the risk of injury and discomfort.
C: Cleaning the perineal area with an antiseptic is important but should be done after removing the catheter.
D: Deflating the balloon halfway and pulling out the catheter can cause pain and discomfort for the client and may lead to trauma.
A nurse is providing discharge teaching to a client following a right mastectomy. Which of the following statements should indicate to the nurse that the client has a healthy body image?
- A. Do I have to go home with drains?
- B. The incision looks like it is healing.
- C. My sister will change the dressing every day.
- D. When will all this pain start to go away?
Correct Answer: B
Rationale: A statement acknowledging the healing process suggests the client is adjusting positively to body image changes.