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A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?
- A. Lightly palpate the skin using the fingertips.
- B. Press the skin over the client's ankle bone.
- C. Observe for nonblanching, pinpoint-size, red or purple spots on the skin of the abdomen.
- D. Grasp a fold of skin on the client's forearm or near the sternum.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Grasping a fold of skin on the client's forearm or near the sternum is the appropriate method to assess skin turgor. Skin turgor is the skin's ability to return to normal after being pinched. By grasping the skin and observing how quickly it returns to its original state, the nurse can assess the client's hydration status accurately. This method is commonly used and recommended for assessing skin turgor.
Incorrect Choices:
A: Lightly palpating the skin using the fingertips does not provide an accurate assessment of skin turgor.
B: Pressing the skin over the client's ankle bone is not the standard method for assessing skin turgor.
C: Observing for nonblanching, pinpoint-size, red or purple spots on the skin of the abdomen is unrelated to assessing skin turgor and indicates a different condition.
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A nurse is caring for an older adult client who expresses feelings of grief for his earlier life. Which of the following actions should the nurse take to help the client cope with his feelings of loss?
- A. Let the client know that this is a common problem of the aging population.
- B. Provide the client with activities to perform so he won't have time to dwell on the past.
- C. Listen attentively when the client talks about the past.
- D. Tell the client about some of the younger clients in the hospital who have experienced loss.
Correct Answer: C
Rationale: The correct answer is C: Listen attentively when the client talks about the past. Active listening is crucial in helping the client cope with feelings of grief. By providing a supportive environment and allowing the client to express his emotions, the nurse can validate his feelings and provide emotional support. This helps the client feel understood and accepted, facilitating the grieving process.
Choice A is incorrect because simply stating that it is a common problem does not address the individual client's feelings. Choice B is incorrect as it dismisses the client's emotions and distracts rather than addressing the root of the issue. Choice D is inappropriate as it is not empathetic and may invalidate the client's experience by comparing it to others.
A nurse identifies an extravasation of a vesicant solution at a client's peripheral IV catheter's insertion site. Identify the sequence in which the nurse should perform the following actions.
- A. Aspirate the solution from the catheter.
- B. Stop the infusion.
- C. Disconnect the tubing from the catheter.
- D. Remove the IV catheter.
- E. Attach a syringe to the catheter.
Correct Answer: B,E,A,C,D
Rationale: The correct sequence is B, E, A, C, D. First, stopping the infusion prevents further harm. Then, attaching a syringe helps to aspirate the vesicant solution. Aspirating the solution reduces tissue damage. Disconnecting the tubing prevents further exposure. Lastly, removing the IV catheter minimizes harm and promotes healing. Incorrect choices: A is incorrect as the solution should be aspirated after stopping the infusion. C is incorrect as disconnecting the tubing should come after aspirating the solution. D is incorrect as removing the IV catheter is the final step after all the previous actions have been completed.
A nurse is caring for a client who has not voided for 8 hr following surgery. Which of the following actions should the nurse take first?
- A. Offer the client fluids.
- B. Perform a bladder scan.
- C. Insert an indwelling urinary catheter.
- D. Provide assistance to bathroom.
Correct Answer: B
Rationale: The correct answer is B: Perform a bladder scan. This is the first action the nurse should take because it provides valuable information about the client's bladder status without invasive intervention. The bladder scan will help determine if the client has urinary retention, which could be the reason for not voiding after surgery. Offering fluids (choice A) is important but should come after assessing the bladder. Inserting a urinary catheter (choice C) is invasive and should only be done if necessary. Providing assistance to the bathroom (choice D) is not appropriate if there is a possibility of urinary retention.
A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?
- A. Explain to the client what is about to happen.
- B. Make sure the room temperature is cool.
- C. Provide music as an environmental distraction.
- D. Inform the client that the provider will examine sensitive areas first.
Correct Answer: A
Rationale: The correct answer is A: Explain to the client what is about to happen. This is important to ensure the client's understanding and cooperation during the physical examination. By explaining the procedure, the nurse can reduce the client's anxiety and build trust. This communication also promotes client autonomy and respects their dignity. As for the other choices: B (Make sure the room temperature is cool) is not directly related to preparing the client for the physical examination. C (Provide music as an environmental distraction) may not be appropriate for all clients and may not address the client's emotional needs. D (Inform the client that the provider will examine sensitive areas first) may cause unnecessary anxiety without providing a clear understanding of the examination process.
A nurse is reviewing the goals of a nurse-client therapeutic relationship with a newly licensed nurse. Which of the following information should the nurse include in the teaching?
- A. The client achieves optimal personal growth.
- B. The nurse forms a personal identity.
- C. The client allows the nurse to satisfy his personal needs.
- D. The nurse's needs take priority over the client's needs.
Correct Answer: A
Rationale: The goal of a therapeutic relationship is to help the client achieve personal growth and well-being.