Nokea
The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?
- A. Perform range-of-motion exercises to prevent contractures.
- B. Decrease the client's fluid intake to prevent diarrhea.
- C. Massage the client's legs to reduce the occurrence of embolisms.
- D. Turn the client from side to back every shift.
Correct Answer: A
Rationale: Performing range-of-motion exercises is essential in preventing contractures, which are common complications of immobility. These exercises help maintain joint flexibility and muscle strength, reducing the risk of contractures that can lead to functional limitations or pain for the client. Choices B, C, and D are incorrect. Decreasing fluid intake does not prevent immobility complications, but it can lead to dehydration. Massaging the client's legs does not directly address the prevention of immobility complications like contractures. Turning the client from side to back every shift is important for preventing pressure ulcers but does not directly address complications of immobility like contractures.
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A client has a nursing diagnosis of 'spiritual distress.' What intervention is best for the nurse to implement when caring for this client?
- A. Use distraction techniques during times of spiritual stress and crisis.
- B. Reassure the client that their faith will be regained with time and support.
- C. Consult with the staff chaplain and request that the chaplain visit with the client.
- D. Use reflective listening techniques when the client expresses spiritual doubts.
Correct Answer: D
Rationale: When a client is going through spiritual distress, employing reflective listening techniques is crucial. This method allows the client to voice their concerns and emotions, providing them with a supportive environment to explore their feelings. Options A and B do not directly address the client's spiritual distress and may undermine the client's feelings. While option C involves a chaplain, using reflective listening directly involves the nurse in addressing and supporting the client's spiritual concerns.
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?
- A. Give analgesics on an around-the-clock schedule for pain management.
- B. Administer analgesic medication only when the pain becomes severe.
- C. Provide medication to keep the client comfortable without inducing sedation.
- D. Allow brief medication-free periods to promote comfort during daily activities.
Correct Answer: A
Rationale: The most effective pain management strategy in hospice care involves administering analgesics on an around-the-clock schedule (A) to maintain pain control. Waiting until pain is severe before administering medication (B) is not ideal as it may lead to inadequate pain relief. While providing comfort is crucial in hospice care, sedation that prevents the client from interacting and experiencing their remaining time should be minimized. Therefore, keeping the client comfortable without excessive sedation (C) is preferred. Allowing for some periods without medication (D) may be appropriate but should not compromise the client's comfort and pain control.
The healthcare provider plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the healthcare provider administer? (Round to the nearest tenth.)
- A. 0.2 mL
- B. 0.8 mL
- C. 1.25 mL
- D. 2.0 mL
Correct Answer: B
Rationale: To calculate the volume to administer, use the formula (1 mL 4 mg) / 5 mg = 0.8 mL. The healthcare provider should administer 0.8 mL of diazepam for a dosage of 4 mg IV push. Choice A is incorrect because it results from an incorrect calculation. Choices C and D are incorrect as they do not align with the correct calculation based on the provided dosage.
A seriously ill female client tells the nurse, 'I am so tired and in so much pain! Please help me to die.' Which is the best response for the nurse to provide?
- A. Administer the prescribed maximum dose of pain medication.
- B. Talk with the client about her feelings related to her own death.
- C. Collaborate with the healthcare provider about initiating antidepressant therapy.
- D. Refer the client to the ethics committee of her local healthcare facility.
Correct Answer: B
Rationale: The nurse should prioritize addressing the client's emotional needs by engaging in a conversation to understand the underlying feelings behind her statement. By exploring the client's thoughts about death, the nurse can provide appropriate support and interventions tailored to the client's concerns. Rushing to administer pain medication may not address the emotional distress expressed by the client. Initiating antidepressant therapy is not suitable without assessing the client's feelings further. Referring the client to the ethics committee is premature and does not address the immediate emotional needs of the client. Therefore, empathetic communication and assessment of the client's feelings regarding her situation are crucial for providing holistic care.
Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?
- A. Perform cough and deep breathing exercises hourly.
- B. Turn from side to side in bed at least every 2 hours.
- C. Dorsiflex and plantarflex the feet 10 times each hour.
- D. Drink approximately 4 ounces of water every hour.
Correct Answer: C
Rationale: The most crucial instruction for a client with limited mobility to prevent venous thrombosis is to perform dorsiflexion and plantarflexion of the feet 10 times each hour. These exercises help promote venous return, reducing the risk of thrombosis by preventing blood stasis in the lower extremities. While other measures like turning in bed and staying hydrated are beneficial, promoting venous return through foot exercises is the priority in preventing venous thrombosis in clients with limited mobility. Dorsiflexion and plantarflexion directly target the calf muscle pump, aiding in the circulation of blood back to the heart and preventing clot formation. The other options, such as cough and deep breathing exercises, turning in bed, and hydration, are important for overall health but do not directly address venous stasis and thrombosis prevention in the same way as foot exercises.