Nokea
The nurse is preparing for the first interaction with a client recently admitted to the hospital. Which of the following would help establish trust during this encounter? Select all that apply.
- A. Make sure the client's bed is set up properly ahead of time.
- B. Review the client's name, diagnosis, and anticipated length of stay before they arrive.
- C. Speak confidently and do not tell the client that one of the nurses providing care is a student nurse.
- D. Show the client how to use the bed and call light.
- E. Avoid spending too much time talking with the client.
- F. Ask about the client's expectations and concerns when taking the health history.
Correct Answer: A,B,D,F
Rationale: Preparing the environment, knowing client details, demonstrating equipment, and addressing concerns build trust. Avoiding student disclosure is deceptive, and limiting talk time hinders rapport.
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While scheduling a client for thoracentesis, the nurse understands which of the following is the most preferred position for the procedimiento?
- A. Sitting up, leaning over a bedside table, and feet supported on the ground or stool.
- B. The head of the bed flat with the patient lying on the unaffected side.
- C. Prone position with both arms extended above the head.
- D. The head of the bed elevated 45 degrees, and the patient lying on the affected side.
Correct Answer: A
Rationale: Sitting up and leaning forward maximizes lung expansion and pleural fluid access for thoracentesis. Other positions restrict access or increase complication risk.
The nurse is inserting an indwelling urinary catheter in a male client. It would be appropriate for the nurse to inflate the catheter's balloon when
- A. Meeting resistance.
- B. As soon as urine is observed in the tubing.
- C. After advancing to the point of bifurcation.
- D. After fully advancing the length of the catheter.
Correct Answer: C
Rationale: The balloon should be inflated after advancing the catheter to the bifurcation (Y-connector), ensuring it is in the bladder. Inflating too early or fully advancing risks trauma or improper placement.
The nurse is assessing a client who had gastric bypass surgery two days ago. The nurse should prioritize assessing the client for
- A. venous thromboembolism
- B. their current weight
- C. nausea and vomiting
- D. surgical site infection
Correct Answer: C
Rationale: Nausea and vomiting are priority assessments post-gastric bypass due to the risk of anastomotic leaks or obstruction, which can be life-threatening. Venous thromboembolism and surgical site infection are concerns but less immediate, and weight assessment is not a priority at this stage.
The nurse plans care for a client immediately post-operative. The nurse should initially assess the client's
- A. respiratory status
- B. tolerance to by-mouth (PO) fluids
- C. pain level
- D. ability to move the extremities
Correct Answer: A
Rationale: Respiratory status is the priority assessment post-operatively to ensure airway patency and adequate oxygenation, following the ABCs (airway, breathing, circulation) of care. Pain, fluid tolerance, and extremity movement are important but secondary to ensuring respiratory stability.
The nurse is caring for a client with a tracheostomy. Which of the following items is essential to have at the bedside?
- A. Air humidifier
- B. Inner cannula
- C. Nasal cannula oxygen
- D. Tracheostomy brush
Correct Answer: B
Rationale: An inner cannula is essential for tracheostomy care to replace or clean it if obstructed. Humidifiers, nasal cannulas, and brushes are not critical bedside items.