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 promote critical thinking.
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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 knows that skin turgor changes with age. Which intervention is most helpful in dealing with normal aging changes of the skin?
- A. Apply a lubricating lotion to the skin.
- B. Pad all bony prominences.
- C. Encourage a high protein diet.
- D. Bathe with a mild soap daily.
Correct Answer: A
Rationale: Lotion combats dryness in aging skin.
A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?
- A. I can only give medical information to the client with an approved interpreter.'
- B. The healthcare provider will share this information with you.'
- C. I'm sorry, but your sibling's medical information is none of your business.'
- D. I can give you those results as soon as I get them back from the lab.'
Correct Answer: A
Rationale: Approved interpreter ensures confidentiality.
The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? (Select all that apply)
- A. Raise the four side rails on the bed.
- B. Close the client's room door.
- C. Orient the client to the surroundings.
- D. Secure a bed alarm on the mattress.
- E. Escort the client back to her room.
Correct Answer: C,D,E
Rationale: Orienting, alarming, and escorting ensure safety.
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.