Nokea
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies.Which of the following is most useful for the nurse to include?
- A. Providing physical demonstration.
- B. Using simulation activities.
- C. Incorporating verbal analogies.
- D. Offering positive reinforcement.
Correct Answer: B
Rationale: Simulation activities provide a safe and controlled environment for young adult clients to practice problem-solving strategies and learn from their experiences.
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What's the priority intervention for a patient with persistent STIs and risky behaviors?
- A. Recommend consistent use of latex condoms.
- B. Discuss the purpose of annual infection screening.
- C. Some infections may have no initial symptoms.
- D. Advise that alcohol intake may lead to risky behaviors.
Correct Answer: A
Rationale: The priority intervention for a patient with persistent STIs and risky behaviors is to recommend consistent use of latex condoms. According to the USPSTF, behavioral counseling is recommended for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs).
The nurse is teaching a client how to self-administer subcutaneous heparin injections.Which instruction should the nurse include?
- A. Inject in abdominal area at least 2 inches from the umbilicus.
- B. Rotate injections between the abdomen and gluteal areas.
- C. Massage the injection site to increase absorption.
- D. Expel the air in the prefilled syringe prior to injection.
Correct Answer: A
Rationale: Inject in abdominal area at least 2 inches from the umbilicus. When administering subcutaneous heparin injections, it is important to choose an injection site on either your tummy or outer areas of your left or right thigh. Your tummy is usually best as the injection site and it is important that you change the site each time.
The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA).Which interaction is most important for the nurse to implement before leaving the client?
- A. Elevate the head of the bed to a 45-degree angle
- B. Apply the client's positive airway pressure device
- C. Lift and lock the side rails in place
- D. Remove dentures or other oral appliances
Correct Answer: B
Rationale: The client has difficulty sleeping due to obstructive sleep apnea (OSA), and using a positive airway pressure device can help keep their airway open and prevent dangerous pauses in breathing while they sleep.
A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours as needed for cough. The bottle is labeled 'Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL'. How many tablespoons should the nurse instruct the client to take within each dose? (Enter numerical value only).
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: A
Rationale: Since the prescription is for 30 mg of dextromethorphan and the bottle is labeled 'Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL', the client should take 15 mL of the suspension per dose. Since there are 15 mL in 1 tablespoon, the client should take 1 tablespoon of the suspension per dose.
Two days after surgery, a male client experiences incisional pain while dangling his feet at the bedside and he refuses to ambulate as prescribed.The nurse establishes a problem of 'Activity intolerance related to pain'. Based on this problem, which outcome statement is best for the nurse to include in his care plan?
- A. To ambulate without discomfort.
- B. To take analgesics as prescribed.
- C. To show evidence of incision healing.
- D. To avoid pain-causing activity.
Correct Answer: A
Rationale: The goal of the care plan should be to help the client overcome his activity intolerance related to pain. This can be achieved by helping him to ambulate without discomfort.