Nokea
The nurse is teaching a diabetic client using an empowerment approach. The nurse should initiate teaching by asking which of the following?
- A. How much does your family need to be involved in learning about your condition?'
- B. What is required for your family to manage your symptoms?'
- C. What activities are most important for you to be able to maintain control of your diabetes?'
- D. What do you know about your medications and condition?'
Correct Answer: D
Rationale: An empowerment approach focuses on the client's knowledge and needs. Starting with what the client already knows about their condition and medications helps tailor education effectively.
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A nursing assistant is providing care to a client with left-sided paralysis. Which of the following actions by the nursing assistant requires the nurse to provide further instruction?
- A. Providing passive range of motion exercises to the left extremities during the bed bath.
- B. Elevating the foot of the bed to reduce edema.
- C. Pulling up the client under the left shoulder when getting out of bed to a chair.
- D. Putting high top tennis shoes on the client after bathing.
Correct Answer: C
Rationale: Pulling under the paralyzed shoulder can cause injury or discomfort. Passive ROM, elevating the bed, and high-top shoes are appropriate for paralysis care.
A client has a chest tube attached to a waterseal drainage system and the nurse notes that the fluid in the chest tube and in the water-seal column has stopped fluctuating. The nurse should determine:
- A. The lung has fully expanded.
- B. The lung has collapsed.
- C. The chest tube is in the pleural space.
- D. The mediastinal space has decreased.
Correct Answer: A
Rationale: Lack of fluctuation in the water-seal column suggests the lung has fully expanded, resolving the pneumothorax. Collapsed lung, tube placement, or mediastinal changes would show other signs.
The nurse finds an unlicensed assistive personnel massaging the reddened bony prominences of a client on bed rest. The nurse should:
- A. Reinforce the aide's use of this intervention over the bony prominences.
- B. Explain that massage is effective because it improves blood flow to the area.
- C. Inform the aide that massage is even more effective when combined with lotion during the massage.
- D. Instruct the aide that massage is contraindicated because it decreases blood flow to the area.
Correct Answer: D
Rationale: Massaging reddened bony prominences is contraindicated, as it can damage fragile tissue and reduce blood flow, worsening the risk of pressure ulcers.
Which assessment finding is expected in the oliguric phase of acute renal failure?
- A. Weight gain.
- B. Hypotension.
- C. Clear urine.
- D. Low BUN levels.
Correct Answer: A
Rationale: Weight gain occurs due to fluid retention in the oliguric phase.
A client with multiple myeloma is admitted with a serum calcium level of 13.2 mg/dL. Which of the following nursing interventions is the priority?
- A. Administer oral calcium supplements.
- B. Encourage ambulation.
- C. Administer I.V. normal saline.
- D. Restrict fluid intake.
Correct Answer: C
Rationale: Hypercalcemia (serum calcium >10.5 mg/dL) in multiple myeloma requires urgent I.V. normal saline to promote calcium excretion and prevent renal damage, making it the priority intervention.