Nokea
The unlicensed assistive personnel (UAP) reports to the nurse that a client refused to bathe for the third consecutive day. What action is best for the nurse to take?
- A. Ask the client why the bath was refused
- B. Ask family members to encourage the client to bathe
- C. Explain the importance of good hygiene to the client
- D. Reschedule the bath for the following day
Correct Answer: A
Rationale: The correct action for the nurse to take is to ask the client why the bath was refused. Understanding the client's reasons for refusal can guide appropriate interventions, respecting client autonomy while addressing any underlying issues. Choice B is not the best course of action as involving family members may not address the client's specific concerns. Choice C, while important, may not directly address the immediate refusal to bathe. Choice D does not address the underlying reasons for the refusal and may not lead to a resolution.
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The nurse is caring for a client with cirrhosis of the liver. Which clinical finding is most concerning?
- A. Jaundice.
- B. Ascites.
- C. Spider angiomas.
- D. Asterixis.
Correct Answer: D
Rationale: The correct answer is D, Asterixis. Asterixis, also known as liver flap, is a sign of hepatic encephalopathy, a severe complication of liver disease that necessitates immediate attention. While jaundice (choice A), ascites (choice B), and spider angiomas (choice C) are common clinical findings in cirrhosis, asterixis is the most concerning due to its association with hepatic encephalopathy, which can lead to altered mental status and even coma. Jaundice, ascites, and spider angiomas are also important signs in cirrhosis, but asterixis indicates a more critical condition requiring urgent intervention.
After receiving a report, the nurse receives the laboratory values for four clients. Which client requires the nurse's immediate intervention? The client who is...
- A. Short of breath after a shower and has a hemoglobin of 8 grams
- B. Bleeding from a finger stick and has a prothrombin time of 30 seconds
- C. Febrile and has a WBC count of 14,000/mm3
- D. Trembling and has a glucose level of 50 mg/dL
Correct Answer: D
Rationale: A glucose level of 50 mg/dL is indicative of hypoglycemia, which requires immediate intervention to prevent further complications. Hypoglycemia can lead to serious consequences such as altered mental status, seizures, and even coma if not promptly addressed. The other options do not present immediate life-threatening conditions that require urgent intervention. Shortness of breath with a hemoglobin of 8 grams may indicate anemia but does not require immediate intervention. Bleeding from a finger stick with a prothrombin time of 30 seconds may suggest clotting issues, which are important but not as immediately critical as hypoglycemia. Being febrile with an elevated WBC count could indicate infection, which is concerning but not as urgently critical as hypoglycemia.
A client admitted to the hospital with advanced liver failure related to chronic alcoholism is exhibiting ascites and edema. Which pathophysiological mechanisms should the nurse identify as responsible for the third spacing symptoms? (Select all that apply.)
- A. Portal hypertension.
- B. Sodium and water retention.
- C. Decreased serum albumin.
- D. All of the above
Correct Answer: D
Rationale: In advanced liver failure related to chronic alcoholism, ascites and edema occur due to multiple pathophysiological mechanisms. Portal hypertension contributes to the development of ascites by increasing pressure in the portal venous system. Sodium and water retention exacerbate fluid accumulation in the third space. Decreased serum albumin levels lead to reduced oncotic pressure, contributing to the movement of fluid into the interstitial spaces. Abnormal protein metabolism further disrupts fluid balance. Therefore, all of the options (A, B, and C) are correct in this scenario, making choice D the correct answer. Choices A, B, and C alone do not fully explain the comprehensive pathophysiological mechanisms involved in the development of ascites and edema in this clinical context.
A new father asks the nurse the reason for placing an ophthalmic ointment in his newborn's eyes. What information should the nurse provide?
- A. Possible exposure to an environmental staphylococcus infection can infect the newborn's eyes and cause visual deficits
- B. The newborn is at risk for blindness from a corneal syphilitic infection acquired from a mother's infected vagina
- C. Treatment prevents tear duct obstruction with harmful exudate from a vaginal birth that can lead to dry eyes in the newborn
- D. State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection
Correct Answer: D
Rationale: The correct answer is D because informing about state law emphasizes the legal requirement and public health rationale behind prophylactic eye treatment to prevent serious infections like gonorrheal or chlamydial ophthalmic infection. Choices A, B, and C are incorrect. Choice A focuses on staphylococcus infection, which is not the primary concern addressed by the prophylactic ointment. Choice B mentions a specific infection acquired from the mother's infected vagina, which is not the main reason for the ophthalmic ointment. Choice C discusses tear duct obstruction and dry eyes, which are not the primary concerns addressed by the prophylactic ointment.
A client is admitted with a diagnosis of pneumonia. Which intervention should the nurse implement to promote airway clearance?
- A. Administer bronchodilators as prescribed.
- B. Encourage increased fluid intake.
- C. Perform chest physiotherapy.
- D. Provide humidified oxygen.
Correct Answer: B
Rationale: Encouraging increased fluid intake is the most appropriate intervention to promote airway clearance in a client with pneumonia. Adequate hydration helps to thin respiratory secretions, making it easier for the client to cough up and clear the airways. Administering bronchodilators (Choice A) may help with bronchospasm but does not directly promote airway clearance. Chest physiotherapy (Choice C) can be beneficial in certain cases but may not be the initial intervention for promoting airway clearance. Providing humidified oxygen (Choice D) can help improve oxygenation but does not specifically target airway clearance in pneumonia.