Nokea
The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?
- A. Analogies.
- B. Role-playing.
- C. Return demonstration.
- D. Journaling.
Correct Answer: B
Rationale: Role-playing builds communication skills.
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The nurse is planning assignments for the staff on a medical-surgical unit. Which task should the nurse assign to the practical nurse (PN)?
- A. Complete an admission assessment.
- B. Access a central venous line.
- C. Reinforce discharge teaching.
- D. Initiate blood product infusions.
Correct Answer: C
Rationale: PNs can reinforce teaching within scope.
After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?
- A. Discontinue the use of the nasal cannula.
- B. Apply lubricant to the cannula tubing.
- C. Place padding around the cannula tubing.
- D. Decrease the flow rate to 1 L/minute.
Correct Answer: C
Rationale: Padding prevents skin breakdown.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?
- A. Complete the intermittent suction of the nasopharynx.
- B. Apply an oxygen mask over the client's nose and mouth.
- C. Reposition the pulse oximeter clip to obtain a new reading.
- D. Stop suctioning until the pulse oximeter reading is above 95%.
Correct Answer: A
Rationale: Stable saturation allows safe continuation of suctioning.
When assessing a client with a serum potassium level of 2.5 mEq/L, which intervention is most important for the nurse to implement?
- A. Observe color and amount of urine.
- B. Determine apical pulse rate and rhythm.
- C. Compare muscle strength bilaterally.
- D. Assess strength of deep tendon reflexes.
Correct Answer: B
Rationale: Hypokalemia risks arrhythmias; pulse is critical.
A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 0 to 10. After placing a call to the healthcare provider, which action should the nurse implement?
- A. Provide at least 20 minutes of back massage and gentle efleurage.
- B. Instruct the client to use guided imagery and slow rhythmic breathing.
- C. Place a hot water circulation device, such as an aquathermia pad, on the operative site.
- D. Tune to a television show or easy listening music to provide distraction.
Correct Answer: A
Rationale: Massage complements pain management.