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What priority nursing action should you take?
- A. Notify the physician immediately
- B. Administer supplemental oxygen
- C. Have the student breathe into a paper bag
- D. Obtain an order for an anxiolytic medication
Correct Answer: C
Rationale: Breathing into a paper bag can help rebalance carbon dioxide levels in a patient experiencing hyperventilation.
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A healthcare professional is interested in making interdisciplinary work a high priority. Which actions by the professional best demonstrate this skill? (Select ONE that does not apply)
- A. Consulting with other disciplines on client care
- B. Coordinating discharge planning for home safety
- C. Participating in comprehensive client rounding
- D. Sharing the care plans with other disciplines
Correct Answer: B
Rationale: The correct answer is B because coordinating discharge planning for home safety is not directly related to interdisciplinary work. The other choices (A, C, D) involve active collaboration and communication with different disciplines to ensure comprehensive client care. Consulting with other disciplines, participating in client rounding, and sharing care plans all demonstrate a high priority on interdisciplinary work by fostering teamwork and integration of various perspectives to enhance patient outcomes. In contrast, coordinating discharge planning for home safety is more focused on individual patient needs and safety rather than interdisciplinary collaboration.
A 72-year-old male client had the Foley catheter removed today, which was inserted during the transurethral resection of the prostate (TURP). The client is concerned about the urinary incontinence he has experienced since removal of the Foley catheter. The nurse should explain to the client that:
- A. he should not be concerned, because it will be quickly resolved.
- B. urinary incontinence is usually temporary.
- C. he should notify the nurse when this happens.
- D. this is related to the bladder spasms and will soon stop.
Correct Answer: B
Rationale: Urinary incontinence is usually temporary, but the problem may take some time to resolve, especially in an older male. Bladder spasms are not the cause of the client's incontinence.
The nurse is caring for a client with benign prostatic hypertrophy. Which of the following assessments would the nurse anticipate finding?
- A. Large volume of urinary output with each voiding.
- B. Involuntary voiding with coughing and sneezing.
- C. Frequent urination.
- D. Urine is dark and concentrated.
Correct Answer: C
Rationale: Frequent urination is common due to urethral obstruction.
A client is receiving discharge teaching after a total hip replacement. Which statement by the client indicates a need for further teaching?
- A. I will avoid crossing my legs when sitting.
- B. I can sleep on my side as long as I use a pillow between my legs.
- C. I will avoid bending at the waist to pick things up.
- D. I can bend down to tie my shoes after 2 weeks.
Correct Answer: D
Rationale: The correct answer is D because bending down to tie shoes after only 2 weeks post total hip replacement can put strain on the hip joint and increase the risk of dislocation. The client should avoid bending past 90 degrees to protect the new hip joint. Choices A, B, and C are all correct statements as they promote hip joint protection and reduce the risk of complications.
A nursing assistant asks why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is your best response?
- A. “The client's low phosphorus is probably due to malnutrition.”
- B. “The client is just worn out from not getting enough rest.”
- C. “The client's skeletal muscles are weak because of the low phosphorus.”
- D. “The client will do more for herself when her phosphorus is normal.”
Correct Answer: C
Rationale: Low phosphorus levels impair energy production in cells, leading to muscle weakness and fatigue, which explains the need for assistance.