Nokea
The nurse is teaching progressive relaxation techniques to a client. Which of the following statements by the client indicates that the teaching has been effective? Select all that apply.
- A. I will breathe in and out in rhythm.
- B. I expect my pulse to be faster afterwards.
- C. I expect to require less pain medication.
- D. I expect my muscles to feel less tense.
- E. I will report any increased sensitivity.
Correct Answer: A,C,D
Rationale: Rhythmic breathing, reduced pain medication needs, and muscle relaxation indicate effective relaxation. Faster pulse and increased sensitivity are incorrect expectations.
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The nurse is counseling a client diagnosed with irritable bowel syndrome (IBS). The nurse should advise the client to increase their
- A. Dairy intake.
- B. Fiber intake.
- C. Fat intake.
- D. Calcium intake.
Correct Answer: B
Rationale: Fiber regulates bowel function in IBS. Dairy and fat may worsen symptoms, and calcium is unrelated to IBS management.
The nurse is caring for a client with a sacral wound infected with Methicillin-resistant staphylococcus aureus. Which personal protective equipment (PPE) is necessary to care for this client? Select all that apply.
- A. Gloves
- B. N95 respirator
- C. Surgical Mask
- D. Goggles
- E. Gown
Correct Answer: A,E
Rationale: MRSA requires contact precautions, including gloves and a gown. N95 respirators, surgical masks, and goggles are not needed unless aerosol-generating procedures are performed.
The infection control nurse reviews guidelines with other nurses. Which of the following statements by the nurses would indicate a correct understanding of the teaching?
- A. The nurse should wear a surgical mask when transporting a client with active pulmonary tuberculosis (TB).
- B. Disposable utensils must be provided for a client infected with hepatitis B.
- C. A surgical mask should be worn when working within three feet of the client infected with Neisseria meningitidis.
- D. A surgical gown should be applied when entering a client's room with bacterial pneumonia.
Correct Answer: C
Rationale: Neisseria meningitidis requires droplet precautions, including a surgical mask within 3 feet. TB requires an N95 mask, hepatitis B does not need disposable utensils, and bacterial pneumonia requires standard precautions.
The nurse is reviewing the vital signs of a client admitted with atrial fibrillation. The client's vital signs are: T 37.5°C (99.6°F), P 88 and irregular, RR 20, BP 90/56 mmHg, pulse oximetry reading 96% on room air. The nurse should immediately address which vital sign?
- A. Temperature
- B. Blood pressure
- C. Respiratory rate
- D. Pulse
Correct Answer: B
Rationale: Low BP (90/56 mmHg) indicates potential hemodynamic instability, requiring immediate attention in atrial fibrillation. Temperature, respiratory rate, and pulse are less critical.
Which of the following clients would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain?
- A. A 36-year-old client with abdominal pain
- B. A 56-year-old client with a below-the-knee amputation and phantom limb pain
- C. A 76-year-old client with terminal cancer
- D. An 84-year-old client with severe arthritis
Correct Answer: B
Rationale: Contralateral stimulation, rubbing the opposite limb, is effective for phantom limb pain by altering pain perception. It is less effective for visceral, cancer, or arthritic pain.