Nokea
When assessing the health beliefs and practices of an older Hispanic adult, the nurse observes that the client uses a traditional folk healer to manage health problems. How would you respond?
- A. Respectfully acknowledge the practice and integrate it where possible.
- B. Discredit the folk healer's methods.
- C. Insist on conventional medical treatment only.
- D. Ignore the client's preference.
Correct Answer: A
Rationale: Respecting and integrating traditional practices fosters trust and collaboration in care delivery.
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What considerations and interventions should be used when caring for a client with a hearing impairment?
- A. Use written communication
- B. Speak loudly and slowly
- C. Provide visual aids
- D. All of the above
Correct Answer: D
Rationale: Using multiple strategies ensures effective communication and accommodation for the client's needs.
When assessing a client with a pneumothorax and a chest tube, which finding should the nurse notify the provider about?
- A. Movement of the trachea toward the unaffected side
- B. Bubbling of the water in the water seal chamber with exhalation
- C. Crepitus in the area above and surrounding the insertion site
- D. Eyelets not visible
Correct Answer: A
Rationale: Step 1: Movement of the trachea toward the unaffected side indicates tension pneumothorax, a life-threatening condition requiring immediate intervention.
Step 2: This finding can lead to compromised breathing and hemodynamic instability if not addressed promptly.
Step 3: B: Bubbling in the water seal chamber with exhalation is expected in a properly functioning chest tube system.
Step 4: C: Crepitus at the insertion site is common due to air entering subcutaneous tissue during tube placement and is not an urgent concern.
Step 5: D: Eyelets not visible can indicate dislodgement but is not as critical as tracheal deviation in this scenario.
Which teaching strategies should the nurse plan to use for a baby boomer patient (select all that apply)?
- A. Podcast
- B. Role playing
- C. Group teaching
- D. Lecture-discussion
Correct Answer: B
Rationale: The correct answers are 'Role playing,' 'Group teaching,' and 'Lecture-discussion.' Baby boomers often prefer interactive and structured learning environments. Podcasts and games may not resonate as well with this demographic.
The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?
- A. Fluctuation of the fluid level within the water seal chamber
- B. Absence of fluid in the drainage tubing
- C. Continuous bubbling within the water seal chamber
- D. Equal amounts of fluid drainage in each collection chamber
Correct Answer: A
Rationale: The correct answer is A: Fluctuation of the fluid level within the water seal chamber. This indicates proper chest tube function as it shows that the system is maintaining the desired pressure and allowing for adequate drainage without obstruction. When the patient breathes in and out, the fluid level fluctuates due to changes in intrathoracic pressure.
Explanation of other choices:
B: Absence of fluid in the drainage tubing - This would indicate a problem with drainage, possibly due to a blockage in the tubing.
C: Continuous bubbling within the water seal chamber - This would suggest an air leak in the system, which is not ideal as it can lead to lung collapse.
D: Equal amounts of fluid drainage in each collection chamber - While equal drainage is good, it does not specifically indicate proper chest tube function like the fluctuation of the fluid level does.
Which of the following would be appropriate to delegate to the nursing assistant?
- A. Assist the child to remove outer clothing
- B. Advise the parent to use acetaminophen instead of aspirin
- C. Explain the need for cool fluids
- D. Prepare and administer a tepid bath
Correct Answer: A
Rationale: Removing outer clothing is a simple task that does not require clinical judgment.