What information should the nurse offer a client who uses herbal therapies to supplement their diet and manage common ailments about the general use of herbal supplements?
- A. Most herbs are toxic or carcinogenic and should only be used when proven effective.
- B. There is no evidence that herbs are safe or effective compared to conventional supplements in maintaining health.
- C. Herbs should be obtained from manufacturers with a history of quality control for their supplements.
- D. Herbal therapies may mask the symptoms of serious diseases, requiring frequent medical evaluations during use.
Correct Answer: C
Rationale: It is essential for clients using herbal therapies to obtain herbs from manufacturers with a history of quality control for their supplements. This recommendation is crucial because quality control processes help in maintaining the purity and effectiveness of the herbal supplements. Option A is incorrect as it provides a negative and inaccurate generalization about herbs. Option B is also incorrect as there is existing evidence on the safety and efficacy of certain herbal supplements. Option D is not the most relevant information to offer initially to a client seeking advice on the general use of herbal supplements.
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A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, 'I have been told that it is harmful to bathe during my period.' Which action should the nurse take first?
- A. Accept and document the client's wish to refrain from bathing.
- B. Offer to give the client a bed bath, avoiding the perineal area.
- C. Obtain written brochures about menstruation to give to the client.
- D. Teach the importance of personal hygiene during menstruation to the client.
Correct Answer: D
Rationale: The priority for the nurse is to educate the client on the importance of personal hygiene during menstruation. Although it's crucial to respect the client's beliefs, providing education ensures the client receives accurate information to make informed decisions about her hygiene practices. By offering teaching first, the nurse can address any misconceptions or concerns the client may have while promoting optimal hygiene practices for overall well-being. Choice A should not be the first action as it does not address the client's potential misinformation about hygiene. Choice B is not ideal as it only offers a temporary solution without addressing the underlying issue. Choice C is not the priority as the immediate concern is the client's personal hygiene practices.
The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?
- A. Encourage the client to increase ambulation in the room.
- B. Offer the client a high-carbohydrate snack for energy.
- C. Force fluids to thin the client's pulmonary secretions.
- D. Determine if pain is causing the client's tachypnea.
Correct Answer: D
Rationale: An increased respiratory rate can be a sign of various issues postoperatively, including pain. Assessing and managing pain is crucial as it can lead to tachypnea. Pain, anxiety, and fluid accumulation in the lungs can all contribute to an increased respiratory rate. Therefore, determining if pain is causing the tachypnea is the most important intervention to address the underlying cause. Encouraging ambulation, offering snacks, or forcing fluids are not the priority in this situation as pain assessment takes precedence in managing the increased respiratory rate.
What instruction should be provided for a UAP caring for a client with MRSA who has an order for contact precautions?
- A. Do not allow visitors until precautions are discontinued
- B. Wear sterile gloves when handling the client's body fluids
- C. Have the client wear a mask whenever someone enters the room
- D. Don a gown and gloves when entering the room
Correct Answer: D
Rationale: The correct instruction for a UAP caring for a client with MRSA under contact precautions is to don a gown and gloves when entering the client's room. This precaution is essential to prevent the spread of MRSA and protect both the client and the healthcare worker from potential infection. Choice A is incorrect because visitors should not be restricted solely based on contact precautions. Choice B is incorrect as wearing sterile gloves is not necessary, standard precautions with regular gloves are sufficient. Choice C is incorrect because the client wearing a mask is not a standard practice for contact precautions; it is the healthcare worker who should take preventive measures.
A client with a diagnosis of hyperkalemia is receiving sodium polystyrene sulfonate (Kayexalate). Which laboratory value should the nurse monitor to evaluate the effectiveness of this medication?
- A. Serum sodium level.
- B. Serum potassium level.
- C. Serum calcium level.
- D. Serum glucose level.
Correct Answer: B
Rationale: The correct answer is B: Serum potassium level. Sodium polystyrene sulfonate (Kayexalate) is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestines, leading to potassium removal from the body. Monitoring the serum potassium level allows the nurse to assess the effectiveness of this medication in lowering the elevated potassium levels. Serum sodium (A), calcium (C), and glucose (D) levels are not directly impacted by the action of sodium polystyrene sulfonate.
Which serum laboratory value should the nurse monitor carefully for a client who has had an NG tube for suctioning for the past week?
- A. White blood cell count
- B. Albumin
- C. Calcium
- D. Sodium
Correct Answer: D
Rationale: The nurse should carefully monitor serum sodium levels for a client with an NG tube on suction for an extended period due to potential fluid loss and the risk of developing hyponatremia, an electrolyte imbalance. Hyponatremia can occur as a result of continual suctioning leading to fluid loss, making it crucial to monitor sodium levels to prevent complications associated with low sodium levels. Monitoring white blood cell count, albumin, or calcium is not directly related to the impact of NG tube suction on fluid and electrolyte balance, so these values are not the priority in this scenario.