Nokea
A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement, and the nurse offers a bed pan. The client states, 'I've always used the bathroom.' Which of the following responses should the nurse make?
- A. Tell me what concerns you have about using a bed pan.'
- B. Make sure to use nearby furniture to support yourself when walking to the bathroom.'
- C. I will have the physical therapist ambulate you to the bathroom.'
- D. You have to use the bed pan for your own safety.'
Correct Answer: A
Rationale: The correct answer is A: "Tell me what concerns you have about using a bed pan." This response demonstrates therapeutic communication by acknowledging the client's feelings and allowing them to express their concerns. By understanding the client's perspective, the nurse can address specific fears or preferences related to using the bed pan. This approach promotes client autonomy and dignity.
Choice B is incorrect because it disregards the client's expressed need for a bowel movement while on complete bed rest. Choice C is inappropriate as it assumes the client is physically able to be ambulated to the bathroom, which may not be the case. Choice D is incorrect as it is a directive statement that does not address the client's concerns or preferences.
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A nurse is providing an in service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who uses a wheelchair and is confused
- B. A client who is bedridden and wears a hearing aid
- C. A client who is ambulatory and receiving oxygen
- D. A client who has a fracture and is in balance suspension traction
Correct Answer: A
Rationale: The correct answer is A because a client who uses a wheelchair and is confused is at the highest risk during a fire evacuation due to mobility limitations and decreased ability to follow instructions. Evacuating this client first ensures their safety and prevents potential delays in the evacuation process.
Choice B is incorrect because a bedridden client wearing a hearing aid can still be safely evacuated with assistance. Choice C is incorrect as an ambulatory client receiving oxygen can usually move independently and should be evacuated after the client in a wheelchair. Choice D is incorrect because a client with a fracture in traction can be safely moved with proper equipment and should not be the first priority for evacuation.
A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?
- A. An induration measuring 10 mm
- B. An induration measuring 5 mm
- C. A reddened area measuring 10 mm
- D. A reddened area measuring 5 mm
Correct Answer: A
Rationale: The correct answer is A: An induration measuring 10 mm. An induration of 10 mm or greater is considered a positive result for a tuberculin skin test in individuals who are at higher risk for tuberculosis. This indicates exposure to the tuberculosis bacteria and an immune response. Choices B, C, and D are incorrect because the presence of redness or a smaller induration size does not meet the criteria for a positive test result. Redness alone does not signify a positive result, and a smaller induration size is not indicative of a positive test. It is important to interpret tuberculin skin tests accurately to guide further testing and treatment decisions.
A nurse is teaching a client about family planning using the basal body temperature method. Which of the following instructions should the nurse include in the teaching?
- A. Take your temperature immediately after waking and before getting out of bed.'
- B. Take your temperature within 30 minutes after your first morning void.'
- C. Take your temperature 1 hour after getting out of bed.'
- D. Take your temperature every night before going to bed.'
Correct Answer: A
Rationale: The correct answer is A: "Take your temperature immediately after waking and before getting out of bed." This instruction is crucial for accurate basal body temperature tracking as it helps to capture the body's resting temperature before any physical activity or external factors can influence it. Option B is incorrect because taking the temperature after voiding may not provide the most accurate reading. Option C is incorrect as waiting one hour after getting out of bed can introduce variability in the readings. Option D is incorrect because taking the temperature at night before bed does not reflect the basal body temperature.
A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal hypoglycemia
- B. Chorioamnionitis
- C. Fetal anemia
- D. Maternal fever
Correct Answer: C
Rationale: Correct Answer: C (Fetal anemia)
Rationale: Fetal anemia can lead to decreased oxygen delivery to the fetus, causing fetal bradycardia. Anemia reduces the oxygen-carrying capacity of the blood, resulting in the heart working harder to compensate for the decreased oxygen levels, leading to a lower fetal heart rate.
Summary of Incorrect Choices:
A: Maternal hypoglycemia - Unlikely to cause fetal bradycardia directly.
B: Chorioamnionitis - Typically presents with maternal fever and tachycardia, not fetal bradycardia.
D: Maternal fever - Can cause fetal tachycardia, not bradycardia.
A nurse is planning care for a client who has acute appendicitis. Which of the following actions should the nurse plan to take?
- A. Place the client's head of bed flat
- B. Apply heat to the client's abdomen
- C. Keep the client on NPO status
- D. Administer a laxative to the client.
Correct Answer: C
Rationale: The correct answer is C: Keep the client on NPO status. This is essential to prevent exacerbation of appendicitis by reducing the risk of bowel obstruction or rupture. Allowing the intestine to rest helps decrease inflammation and pain. Placing the client's head of bed flat (A) can increase intra-abdominal pressure, worsening the condition. Applying heat to the abdomen (B) can mask symptoms and potentially lead to delay in diagnosis. Administering a laxative (D) is contraindicated as it can increase the risk of perforation. In summary, maintaining NPO status is crucial for managing acute appendicitis effectively.