Nokea
The nursing staff is planning to use behavior modification techniques for an elderly woman who constantly screams. Which of the following nursing assessments is necessary to establish a successful program?
- A. Monitor the client's ability to complete her activities of daily living (ADL).
- B. Assess the client's levels of pain and correlate it with her response to analgesia.
- C. Observe the client's behavior at regular intervals to obtain baseline information related to her screaming.
- D. Ask the client why she is screaming and document it on her nursing assessment record.
Correct Answer: C
Rationale: to design an effective behavior modification program, accurate baseline data must first be collected about the target behavior in relation to frequency, amount, time, and precipitating factors
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The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the PRIORITY?
- A. Check the ventilator settings every shift.
- B. Suction the endotracheal tube as needed.
- C. Monitor the client’s oxygen saturation.
- D. Ensure the endotracheal tube is secure.
Correct Answer: D
Rationale: Ensuring the endotracheal tube is secure is the priority to prevent accidental extubation, which could lead to respiratory failure. Options A, B, and C are important but secondary: checking settings, suctioning, and monitoring saturation follow tube security.
The nurse is caring for clients in the skilled nursing facility.
- A. Which client requires the nurse’s immediate attention?
- B. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired two days ago.
- C. A client in pain who was receiving morphine in an acute care institution and was transferred with a prescription for acetaminophen with codeine.
- D. A client who has dysuria and foul-smelling, cloudy, dark amber urine.
- E. An immunosuppressed client who has not received an influenza immunization.
Correct Answer: A
Rationale: A client with an expired warfarin prescription post-CVA is at high risk for recurrent stroke due to the anticoagulant’s 2-5 day duration, requiring immediate attention. Pain management, urinary symptoms, and immunization are less urgent.
Twenty-four hours after abdominal surgery.
Which of the following plans would be a nursing priority to prevent complications of flatulence?
- A. Encourage the client to drink carbonated beverages daily.
- B. Instruct the client to turn from side to side.
- C. Encourage the client to do leg exercises in bed.
- D. Assist the client to walk in the hall every 2 hours.
Correct Answer: D
Rationale: Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) increasing carbonated beverages will increase flatus (2) will prevent postoperative complications, but not flatulence (3) does not address flatulence (4) correct-will increase peristalsis, decreasing the development of flatus
A college student was in a motor vehicle accident six months ago. Although he was minimally injured, his friend was killed. The client comes to Student Health Services with complaints of not being able to study, not sleeping, and thinking he's 'going crazy.'
It is MOST important for the nurse to
- A. perform a complete physical and social history.
- B. obtain a complete drug and alcohol history, including reports from a drug screen.
- C. review the significant events of the last year.
- D. explore how he coped with the motor vehicle crash and his friend's death.
Correct Answer: D
Rationale: Strategy: Determine the outcome of each answer choice. (1) not most important initially (2) not most important initially (3) not most important initially (4) correct-initially obtaining focused information about a very traumatic event is helpful and provides the nurse with an opportunity to understand how this client has coped with a tragedy that has made him vulnerable
A patient is admitted with abdominal pain and nausea. The physician orders stool for guaiac times three days.
The nurse asks the health care technician to obtain the stool specimen. Which of the following statements, if made by the technician, would require an intervention by the nurse?
- A. I'll remind the patient to use the bedpan instead of the bathroom toilet.
- B. I'll use a tongue blade to collect a small amount of stool in a clean container.
- C. I'll get a couple of specimens this afternoon because the patient is having loose stools.
- D. I'll ask the patient if he has ingested any red meat recently.
Correct Answer: C
Rationale: Strategy: Each answer choice is an implementation. Determine the outcome of each answer choice. Is it desired? (1) easier to get specimen (2) doesn't need to be sterile container (3) correct-ordered to be collected over 3-day period (4) may cause false-positive reading