Nokea
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?
- A. Incorporate verbal analogies.
- B. Offer positive reinforcement.
- C. Provide physical demonstrations.
- D. Use simulation activities.
Correct Answer: D
Rationale: Simulations engage active problem-solving.
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A female client who is receiving hospice care in her home expresses fear that dying will be painful. Which action should the nurse take first?
- A. Include caregiver in discussion of pain relief strategies.
- B. Encourage the client to talk about her fear related to pain.
- C. Explain that analgesics will be given whenever needed.
- D. Provide therapeutic touch along with comfort and support.
Correct Answer: B
Rationale: Discussing fears allows personalized reassurance.
The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize the client is at greater risk for the development of which complication?
- A. Hypothyroidism.
- B. Hypertension.
- C. Peptic ulcer disease.
- D. Fibromyalgia.
Correct Answer: B
Rationale: Sleep apnea increases hypertension risk due to oxygen desaturation.
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. Stop suctioning until the pulse oximeter reading is above 95%.
- B. Reposition the pulse oximeter clip to obtain a new reading.
- C. Complete the intermittent suction of the nasopharynx.
- D. Apply an oxygen mask over the client's nose and mouth.
Correct Answer: B
Rationale: Repositioning ensures accurate saturation readings.
The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?
- A. Remove the coffee from the tray, advising the client that it is not included in the diet.
- B. Determine which member of the nursing staff brought the cup of coffee to the client.
- C. Remind the client that no milk or creamer can be added to the coffee.
- D. Consult with the dietician to learn if the client is allowed to drink coffee.
Correct Answer: C
Rationale: Black coffee is allowed without additives.
The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?
- A. Temperature.
- B. Blood pressure.
- C. Heart rate.
- D. Respiratory rate.
Correct Answer: D
Rationale: Cyanosis suggests respiratory issues, needing immediate assessment.