What would be the best response by the nurse to a quiet and uncommunicative client?
- A. Think over the following questions.
- B. Discuss them with your instructor or peers.
- C. Acknowledge their feelings and encourage expression.
- D. Offer silence and wait patiently.
Correct Answer: D
Rationale: Silence can provide the client with space to open up when they feel ready, fostering trust and rapport.
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A client is vomiting. Which of the following actions should the nurse take first?
- A. Provide the client with an emesis basin
- B. Notify housekeeping
- C. Prevent the client from aspirating
- D. Administer an antiemetic to the client
Correct Answer: C
Rationale: The correct action for the nurse to take first is to prevent the client from aspirating. Aspiration is a serious risk when a client is vomiting as it can lead to respiratory complications. The nurse should position the client on their side to prevent aspiration of vomitus into the airway. This immediate action takes priority over providing an emesis basin, notifying housekeeping, or administering an antiemetic, which do not address the urgent need to prevent aspiration.
Which of the following helps the nurse to identify goals, tailor the teaching plan, and evaluate outcomes?
- A. Desire to acquire new information.
- B. Assessment of what the client knows.
- C. Purpose or reason for mastering skills.
- D. Restored independence.
Correct Answer: B
Rationale: Assessing the client's existing knowledge provides a foundation for setting realistic goals and tailoring the teaching plan.
What is a mental status assessment of the older adult especially important in determining?
- A. Potential for independent living
- B. Eligibility for federal health programs
- C. Service and placement needs of the individual
- D. Whether the person should be classified as frail
Correct Answer: C
Rationale: Mental status assessments help determine appropriate services and placements based on cognitive and functional abilities.
For a patient who is experiencing side effects of radiation therapy, which task would be the most appropriate to delegate to the nursing assistant?
- A. Assist the patient to identify patterns of fatigue.
- B. Recommend participation in a walking program.
- C. Report the amount and type of food consumed from the tray.
- D. Check the skin for redness and irritation after the treatment.
Correct Answer: C
Rationale: Monitoring food intake is a straightforward task suitable for a nursing assistant, while identifying fatigue patterns or recommending exercise requires more clinical expertise.
Which nursing actions are completed by the scrub nurse (select all that apply)?
- A. Prepares instrument table
- B. Documents intraoperative care
- C. Remains in the sterile area of the OR
- D. Checks mechanical and electrical equipment
Correct Answer: A
Rationale: The scrub nurse manages sterile instruments and assists the surgical team within the sterile field.
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