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The nurse is teaching the client, who is 24 hours post abdominal surgery, how to use an IS. Which instructions should the nurse include in the teaching? Select all that apply.
- A. Inhale slowly and deeply through mouth
- B. Seal lips tightly around mouthpiece
- C. After inhaling, hold breath for 2 to 3 seconds
- D. Sit with the HOB down and bed almost flat
- E. Splint the incision with pillows
- F. Exhale forcefully, fast, and hard
Correct Answer: A,B,C,E
Rationale: A: Deep inhalation maximizes alveolar inflation. B: Sealing prevents air leaks. C: Holding breath enhances lung expansion. E: Splinting reduces pain, aiding inhalation. D: High Fowler's position is optimal. F: Slow exhalation prevents hyperventilation.
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The nurse is developing guidelines to assist personnel in meeting the hygiene needs of clients with dementia. Which guidelines are appropriate for the nurse to include? Select all that apply.
- A. To limit the client's ability to physically resist, two staff should quickly bathe the client.
- B. Include music and dim lighting to create a calm environment when giving a bed bath.
- C. Allow clients who are willing and able to participate in some of the hygienic activities.
- D. Assess for and treat the client's pain before initiating hygienic cares with the client.
- E. Wash the client's hair and body separately if either activity causes the client distress.
Correct Answer: B,C,D,E
Rationale: B: Calm environments reduce agitation. C: Participation fosters cooperation. D: Pain management improves compliance. E: Separating tasks minimizes distress. A: Quick bathing increases agitation.
The nurse is caring for a patient who is hard-of-hearing. Which of the following steps may be appropriate when communicating with the patient?
- A. Divide the verbal communication into smaller sections and address one at a time.
- B. Communicate only with written information.
- C. Ask multiple questions in a row quickly to make sure the client is remaining engaged.
- D. Frequently communicate without assistive devices to help the client improve their hearing.
Correct Answer: A
Rationale: For a client who is hard-of-hearing, verbal communication should be kept concise. If assistive devices are available, they should be used.
At what point in the nurse-client relationship should termination first be addressed?
- A. in the working phase
- B. in the termination phase
- C. in the orientation phase
- D. when the client initially brings up the topic
Correct Answer: C
Rationale: The client has a right to know the parameters of the nurse-client relationship. If the relationship is to be time limited, the client should be informed of the number of sessions. If it is open-ended, the termination date is not known at the outset, and the client should know that this is an issue that is negotiated at a later date.
The nurse is taking the client's temperature. What should the nurse do to correctly obtain the temperature with a tympanic thermometer?
- A. Ensure that the probe tip seals the ear canal prior to taking a temperature.
- B. Irrigate the ear canal with sterile saline before obtaining the temperature.
- C. When inserting the thermometer in the adult ear, pull downward on the pinna.
- D. Check to be sure that the client does not have any tympanostomy tubes in place.
Correct Answer: A
Rationale: A: Sealing the ear canal ensures accurate readings. B: Irrigation is unnecessary and affects results. C: The pinna is pulled upward in adults. D: Tympanostomy tubes don't affect readings after initial placement.
A nurse is assessing a patient in the ICU. The patient has the following signs: weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?
- A. Hypoglycemic patient
- B. Hyperglycemic patient
- C. Cardiac arrest
- D. End-stage renal failure
Correct Answer: B
Rationale: All of the clinical signs indicate a hyperglycemic condition.