Nokea
What will ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed?
- A. Place the pillow under the patient's head and shoulders.
- B. Attempt to do it alone if the bed is in a flat position.
- C. Place the side rails in the up position.
- D. Use a friction-reducing device.
Correct Answer: D
Rationale: To ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed, it is essential to use a friction-reducing device. This device helps reduce the risk of injury to both the patient and the healthcare provider by minimizing the effort required to reposition the patient. Placing a pillow under the patient's head and shoulders (Choice A) may provide comfort but does not address the safety concerns associated with moving the patient. Attempting to move the patient alone (Choice B) is not recommended as it can lead to injuries for both the patient and the healthcare provider. Placing the side rails in the up position (Choice C) may not directly contribute to the safe movement of the patient in this scenario.
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A client has been diagnosed with terminal cancer. Which of the following interventions is a priority?
- A. Teach the client to use progressive relaxation techniques.
- B. Help the client find a local support group.
- C. Discuss the client's prior coping mechanisms.
- D. Develop a list of goals with the client.
Correct Answer: D
Rationale: When a client receives a terminal cancer diagnosis, it is crucial to prioritize developing a list of goals with the client. This process helps the client focus on what is important to them, set achievable objectives, and maintain a sense of purpose and control. Teaching relaxation techniques (choice A) may be beneficial for symptom management but is not the priority when confronting a terminal illness. While finding a local support group (choice B) can be valuable for emotional support, it does not directly address setting goals. Discussing prior coping mechanisms (choice C) can provide insights into the client's coping strategies but may not be as essential as establishing future goals in the face of a terminal illness.
A client requires rectal temperature monitoring, and a nurse has a thermometer with a long, slender tip at the bedside. What is the appropriate action for the nurse to take?
- A. Obtain a thermometer with a short, blunt insertion end
- B. Use the available thermometer as is
- C. Request a new thermometer
- D. Measure the temperature orally instead
Correct Answer: A
Rationale: When monitoring rectal temperature, it is crucial to use a thermometer with a short, blunt insertion end to prevent injury and ensure accurate readings. Using a thermometer with a long, slender tip can pose a risk of perforation or discomfort for the client. Therefore, the appropriate action for the nurse to take is to obtain a thermometer with a short, blunt insertion end. Using the available thermometer as is would not address the safety concerns. Requesting a new thermometer is unnecessary when a suitable one is available by just obtaining it. Measuring the temperature orally instead would not provide the required rectal temperature monitoring.
A client in the terminal stage of cancer is crying. What action should the nurse take?
- A. Sit and hold the client's hand
- B. Encourage the client to talk about their feelings
- C. Leave the client alone to cry
- D. Ignore the client's crying
Correct Answer: A
Rationale: In situations where a client is in the terminal stage of cancer and crying, it is essential for the nurse to provide comfort and support. Sitting with the client and holding their hand can offer a sense of presence and emotional support, showing empathy and understanding. Encouraging the client to talk about their feelings (choice B) is also important, but initially, non-verbal support through physical presence can be comforting. Leaving the client alone to cry (choice C) can make the client feel abandoned and unsupported during a vulnerable moment. Ignoring the client's crying (choice D) is not appropriate and lacks compassion and empathy, which are crucial in end-of-life care.
A healthcare professional is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the healthcare professional use to obtain the temperature?
- A. Temporal
- B. Oral
- C. Rectal
- D. Axillary
Correct Answer: C
Rationale: In a 2-year-old child with diarrhea and a possible ear infection, rectal temperature measurement is the most accurate reflection of core body temperature. This method provides the most reliable reading, especially in young children, as it closely reflects the core body temperature. Oral temperature may not be accurate due to the child's recent diarrhea, which can affect oral readings. Axillary temperature may not be as accurate as rectal temperature in this case. Temporal temperature measurement, although non-invasive, may not provide the most accurate core body temperature reading, especially in a child with a potential ear infection.
The nurse manager hears a healthcare provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the healthcare provider's complaints. The nurse manager's next action should be to
- A. Approach the healthcare provider and staff nurse for a private meeting to address the situation.
- B. Allow the staff nurse to handle this situation without interference.
- C. Notify other administrative personnel of a breach of professional conduct.
- D. Request an immediate private meeting with the healthcare provider and staff nurse.
Correct Answer: D
Rationale: The correct action for the nurse manager in this situation is to request an immediate private meeting with the healthcare provider and staff nurse. By doing so, the nurse manager can facilitate a more appropriate and professional discussion of the issues at hand in a private setting. Option A, which involves addressing the behavior quietly, may not effectively resolve the issue as it needs to be openly discussed. Option B is not advisable as the nurse manager should intervene to address the situation and provide support. Option C, notifying other administrative personnel, may escalate the situation unnecessarily before attempting to resolve it directly with the involved parties.