Nokea
When gathering subjective data from a client, what intervention should the nurse implement first?
- A. Listen attentively
- B. Establish rapport
- C. List problems
- D. Clarify inferences
Correct Answer: B
Rationale: Establishing rapport is the initial step the nurse should take when gathering subjective data from a client. Building trust and a good relationship with the client creates an environment where the client feels comfortable sharing accurate and honest information. Listening attentively is important but should come after rapport is established to enhance active listening. Listing problems and clarifying inferences are actions that occur later in the assessment process, after the nurse has established a good rapport and obtained a comprehensive understanding of the client's perspective. Therefore, option B is the correct answer.
You may also like to solve these questions
Which action should the nurse include in the plan of care for a client receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)?
- A. Initiate cardiac telemetry monitoring
- B. Maintain continuous pulse oximetry
- C. Perform capillary glucose measurements
- D. Monitor serum creatinine levels
Correct Answer: D
Rationale: The correct answer is D: Monitor serum creatinine levels. Acyclovir can lead to nephrotoxicity, making it essential to monitor kidney function through serum creatinine levels. While cardiac telemetry monitoring (choice A) and maintaining continuous pulse oximetry (choice B) are important in certain conditions, they are not directly related to acyclovir therapy for herpes zoster. Performing capillary glucose measurements (choice C) is not a priority when administering acyclovir for herpes zoster. Monitoring serum creatinine levels is crucial to detect any potential renal issues early, as the drug's nephrotoxic potential requires close monitoring of kidney function.
Prior to surgery, written consent must be obtained. What is the nurse's legal responsibility with regard to obtaining written consent?
- A. Validate the client's understanding of the surgical procedure to be conducted
- B. Explain the surgical procedure to the client and ensure the client comprehends before signing the consent form
- C. Ensure the client, not a family member, signs the surgical consent form
- D. Confirm that the surgical consent form is signed and included in the client's record
Correct Answer: A
Rationale: The nurse's legal responsibility in obtaining written consent is to validate the client's understanding of the surgical procedure to be conducted. This process ensures that the client has been comprehensively informed about the procedure, including its risks, benefits, and alternatives. Choice B is incorrect because it does not emphasize the validation of client understanding, which is crucial for informed consent. Choice C is incorrect as the client, not a family member, should provide consent unless specific circumstances dictate otherwise. Choice D is incorrect because although ensuring the consent form is signed and filed is important, it does not address the primary responsibility of confirming the client's comprehension and ensuring informed consent.
A client with type 2 diabetes mellitus is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), should the nurse report to the healthcare provider? (Select all that apply.)
- A. Increased heart rate
- B. Visual disturbances
- C. Presence of uremic frost
- D. Decreased mentation
Correct Answer: A
Rationale: The correct signs and symptoms indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) include increased heart rate, visual disturbances, and decreased mentation. These symptoms are often associated with HHNS due to the high blood glucose levels. Uremic frost, a sign of advanced kidney disease, is not typically associated with HHNS. Therefore, choices B and D are incorrect. However, choice C, 'Presence of uremic frost,' is incorrect as it is not typically associated with HHNS.
A client with complaints of shortness of breath and abdominal pain 1 week after bariatric surgery is admitted for follow-up evaluation. Which assessment finding warrants immediate intervention by the nurse?
- A. Rectal temperature of 101°F
- B. Complaints of left shoulder pain
- C. Blood pressure of 88/50 mmHg
- D. Sustained sinus tachycardia
Correct Answer: C
Rationale: A blood pressure of 88/50 mmHg indicates possible hypovolemia or shock, which requires immediate attention. Hypotension can be a sign of decreased perfusion to vital organs, potentially leading to organ failure. The other options, such as a rectal temperature of 101°F, complaints of left shoulder pain, or sustained sinus tachycardia, while important, do not present the same level of immediate threat to the client's well-being as a critically low blood pressure.
The client had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours?
- A. Insert an indwelling urinary catheter
- B. Monitor for the appearance of an incisional hernia
- C. Instruct the client to eat small frequent meals
- D. Measure hourly urinary output
Correct Answer: D
Rationale: Monitoring hourly urinary output is crucial during the first 24 postoperative hours to assess kidney function, fluid balance, and early detection of complications like dehydration or inadequate kidney perfusion. Inserting an indwelling urinary catheter is not routinely necessary after gastric bypass surgery unless there are specific indications. Monitoring for an incisional hernia is important but not the highest priority in the immediate postoperative period. Instructing the client to eat small frequent meals is essential for long-term dietary management after gastric bypass surgery, but not the most critical intervention during the initial 24 hours.