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The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA).Which interaction is most important for the nurse to implement before leaving the client?
- A. Elevate the head of the bed to a 45-degree angle
- B. Apply the client's positive airway pressure device
- C. Lift and lock the side rails in place
- D. Remove dentures or other oral appliances
Correct Answer: B
Rationale: The client has difficulty sleeping due to obstructive sleep apnea (OSA), and using a positive airway pressure device can help keep their airway open and prevent dangerous pauses in breathing while they sleep.
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The nurse is using guided imagery with a client who is experiencing chronic pain.What should the nurse direct the client's attention on during the session?
- A. Positive external places.
- B. Motivational phrases.
- C. Tranquil sounds.
- D. Emotional reflection.
Correct Answer: A
Rationale: Guided imagery involves creating a specific imagined reality for yourself. These techniques can be self-taught or guided by a professional. The more you're able to use your imagination and engage your senses, the greater the benefits.
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies.Which of the following is most useful for the nurse to include?
- A. Providing physical demonstration.
- B. Using simulation activities.
- C. Incorporating verbal analogies.
- D. Offering positive reinforcement.
Correct Answer: B
Rationale: Simulation activities provide a safe and controlled environment for young adult clients to practice problem-solving strategies and learn from their experiences.
The nurse is caring for a client who has only months predicted to live. The client avoids questions regarding plans for care.What is the next approach for the nurse to use when discussing end of life issues with the client?
- A. Ask questions in a vague, nonspecific format.
- B. Get the most difficult questions over with first.
- C. Begin with questions that are less sensitive in nature.
- D. Share personal values to put the client at ease.
Correct Answer: C
Rationale: Nurses who provide end of life care are trained to communicate in a way that is concise, yet sensitive. A personalized approach is often taken to meet the unique communication needs of each patient and to recognize when a person may be in pain or distressed.
A client is in contact isolation due to a stage IV coccyx wound infected with MRSA. The nurse plans interventions to prevent multiple infections.Which intervention is most appropriate to prevent the spread of MRSA to others?
- A. Change coccyx dressing after performing routine care.
- B. Change coccyx dressing before performing routine care.
- C. Restate the vital importance of performing hand hygiene.
- D. Perform coccyx dressing change in the nursing station.
Correct Answer: C
Rationale: Restate the vital importance of performing hand hygiene. The most effective way to prevent MRSA is frequent hand washing.
The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?
- A. Blood pressure.
- B. Respiratory rate.
- C. Temperature.
- D. Pulse rate.
Correct Answer: B
Rationale: If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation. Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation. Therefore, the nurse should obtain the respiratory rate first.