Nokea
The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home?
- A. Determine how well the client can change the dressing.
- B. Ask the client to demonstrate the procedure.
- C. Seek a family member's opinion on the client's dressing change ability.
- D. Observe the client change the dressing unassisted.
Correct Answer: D
Rationale: The best method for the nurse to evaluate the client's ability to perform a dressing change at home is by observing the client change the dressing unassisted. Direct observation allows the nurse to assess if the client has mastered the skill and provides an opportunity to confirm the proficiency. Options A, B, and C do not offer the same level of assessment as direct observation. Option A incorrectly focuses on the client's feelings rather than their actual performance ability. Option B, asking the client to demonstrate the procedure, may not accurately reflect their practical skills. Option C, seeking a family member's opinion, introduces potential bias and may not provide an accurate assessment of the client's ability to perform the dressing change independently.
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The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify the placement of the IV access?
- A. Left brachial vein
- B. Right cephalic vein
- C. Dorsal side of the right wrist
- D. Right upper extremity
Correct Answer: B
Rationale: The correct answer is the right cephalic vein. The cephalic vein is a large and superficial vein commonly used for IV access. Documenting the specific anatomic name of the vein used for IV access, such as the cephalic vein, is essential for accurate medical records. Option A, the left brachial vein, is incorrect as the brachial vein is too deep to be accessed for IV infusion. Option C, the dorsal side of the right wrist, is not a recommended IV access site due to fragile veins and potential pain for the patient. Option D, right upper extremity, is too broad and lacks the specificity necessary for precise documentation of the IV access site.
A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment?
- A. Notify the friend that all medical information will be kept confidential.
- B. Explain the relationship to the charge nurse and ask for reassignment.
- C. Approach the client and ask if the assignment is uncomfortable.
- D. Accept the assignment but protect the client's confidentiality.
Correct Answer: B
Rationale: When a nurse is assigned to care for a close friend, it is essential to maintain professional boundaries to ensure the best care for the client and the nurse. The most appropriate action for the nurse to take first is to explain the relationship to the charge nurse and ask for reassignment (B). This is important to avoid potential conflicts of interest and maintain objectivity in the care provided. Option A, notifying the friend about confidentiality, may not address the underlying issue of the conflict of interest. Option C, asking the client if the assignment is uncomfortable, may not be appropriate as it puts the client in a difficult position. Option D, accepting the assignment but protecting the client's confidentiality, does not address the conflict of interest and potential ethical issues that may arise from caring for a close friend.
A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?
- A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows.
- B. Instruct the UAP not to wake the client under any circumstances during the night.
- C. Place a 'Do Not Disturb' sign on the door and change assessments from every 4 to every 8 hours.
- D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.
Correct Answer: A
Rationale: By determining the client's usual bedtime routine and incorporating these rituals into the care plan, the nurse can help the client fall asleep faster and improve the quality of care without compromising safety. This approach respects the client's individual needs and preferences. In contrast, options B, C, and D do not address the client's sleep issue effectively and may even compromise the client's safety or standard of care. Option B fails to address the underlying problem of the client's sleep disturbance, while option C reduces the frequency of assessments, which can impact the timely identification of changes in the client's condition. Option D focuses on pain medication and daytime napping, which are not directly related to the client's current sleep difficulties.
A 20-year-old female client with noticeable body odor has refused to shower for the last 3 days. She states, 'I have been told that it is harmful to bathe during my period.' Which action should the nurse take first?
- A. Accept and document the client's wish to refrain from bathing.
- B. Offer to give the client a bed bath, avoiding the perineal area.
- C. Obtain written brochures about menstruation to give to the client.
- D. Teach the importance of personal hygiene during menstruation to the client.
Correct Answer: D
Rationale: The correct answer is to teach the importance of personal hygiene during menstruation to the client. While respecting the client's beliefs, it is essential to provide education on maintaining hygiene during menstruation. This empowers the client with knowledge to make informed decisions. Options A and B can be considered after providing education. Option C, obtaining brochures, is not the priority as direct communication and teaching would be more effective in addressing the client's concerns.
The healthcare provider is assessing several clients before surgery. Which factor in a client's history poses the greatest threat for complications during surgery?
- A. Taking birth control pills for the past 2 years
- B. Taking anticoagulants for the past year
- C. Recently completing antibiotic therapy
- D. Having taken laxatives PRN for the last 6 months
Correct Answer: B
Rationale: The correct answer is taking anticoagulants for the past year. Anticoagulants increase the risk of bleeding during surgery, which can lead to complications. It is crucial for the healthcare provider to be aware of this medication. While clients taking birth control pills (option A) may be more prone to developing blood clots, these issues typically arise after surgery. Clients who recently completed antibiotic therapy (option C) or have taken laxatives PRN for the last 6 months (option D) are at lower risk compared to those taking anticoagulants (option B) during surgery.