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.
You may also like to solve these questions
The nurse is teaching a group of women at a community center about risk factors for spousal abuse. Which would the nurse identify as risk factors? Select all that apply.
- A. alcohol or drug use
- B. low income or poverty
- C. being over the age of 40
- D. a higher level of education
- E. having a large circle of friends
- F. pregnancy, especially if it is unplanned
Correct Answer: A,B,F
Rationale: Alcohol/drug use, poverty, and unplanned pregnancy are established risk factors for spousal abuse. Age, education, and social circles are not specific risk factors.
The client prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct?
- A. Place the client in a high Fowler position.
- B. Assist the client in assuming a left side-lying position.
- C. Measure the tube from the tip of the nose to the xiphoid process.
- D. Assist the client in flexing the neck forward to facilitate tube insertion.
Correct Answer: A
Rationale: The correct intervention during nasogastric tube insertion in an awake and alert client is to place them in a high Fowler position (A). Left side-lying position (B) is more suitable for unconscious or obtunded clients. When measuring the tube length, it should be from the tip of the nose to behind the ear, and then from behind the ear to the xiphoid process (C). Assisting the client in flexing the neck forward (D) is appropriate to facilitate tube insertion rather than extending the neck back, which may lead to complications. Proper positioning and measurements are crucial to prevent complications and ensure successful nasogastric tube placement.
An older client is admitted to the hospital with a fractured hip and is experiencing periods of confusion. The nurse develops a plan of care and should identify which psychosocial outcome as having the greatest impact on improving the client's cognitive abilities?
- A. Improved sleep patterns
- B. Reduced family fears and anxiety
- C. Meeting self-care needs independently
- D. Increased ability to concentrate and participate in care
Correct Answer: D
Rationale: The client needs to be able to concentrate and participate in her or his care. When the client is able to do that, the nurse can work with the client to achieve the other outcomes. Options 1 and 3 address physiological needs rather than psychosocial outcomes. Option 2 is a secondary need and does not address the client.
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?
- A. Decrease intake of fluids after the evening meal.
- B. Drink a glass of cranberry juice every day.
- C. Drink a glass of warm decaffeinated beverage at bedtime.
- D. Consult the healthcare provider about a sleeping pill.
Correct Answer: A
Rationale: Nocturia is characterized by urination during the night, disrupting sleep patterns. Instructing the client to decrease intake of fluids after the evening meal (Option A) can help reduce the production of urine, thereby decreasing the need to void at night. Cranberry juice (Option B) is beneficial for preventing bladder infections but does not address the issue of nocturia. While warm decaffeinated beverages (Option C) may promote sleep, consuming fluids close to bedtime can exacerbate nocturia. Consulting the healthcare provider about a sleeping pill (Option D) is not the first-line intervention and may lead to urinary incontinence if the client is sedated and unable to awaken to void, worsening the nocturia issue.
Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client?
- A. Maintain standard precautions.
- B. Initiate contact isolation measures.
- C. Insert an indwelling urinary catheter.
- D. Instruct the client in the use of adult diapers.
Correct Answer: A
Rationale: The correct intervention for a nursing diagnosis of risk for infection in an older incontinent client is to maintain standard precautions. The best way to reduce the risk of infection in vulnerable clients is through proper handwashing and adherence to standard precautions. Option B, initiating contact isolation measures, is excessive unless the client has a confirmed infection requiring isolation. Option C, inserting an indwelling urinary catheter, actually increases the risk of infection due to the introduction of a foreign body. Option D, instructing the client in the use of adult diapers, does not directly address the risk of infection and is not as effective as maintaining standard precautions in preventing infection transmission.