Nokea
When performing an abdominal assessment on a client, what action should the nurse take first?
- A. Palpate the abdomen
- B. Auscultate bowel sounds
- C. Inspect the abdomen
- D. Percuss the abdomen
Correct Answer: B
Rationale: The correct answer is to auscultate bowel sounds. This action should be taken first because it ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen (choice C) may provide visual cues but does not address functional assessment. Palpating the abdomen (choice A) should follow auscultation to prevent altering bowel sounds. Percussing the abdomen (choice D) is typically done after auscultation and palpation.
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A nurse is teaching about food choices for a client on a low-sodium diet. What food should the nurse recommend?
- A. Canned soup
- B. Fresh fruit
- C. Processed meats
- D. Frozen meals
Correct Answer: B
Rationale: Fresh fruit is a good option for clients on a low-sodium diet as it is naturally low in sodium. Canned soup, processed meats, and frozen meals tend to be high in sodium due to added salt and preservatives, making them unsuitable choices for individuals on a low-sodium diet.
A client with a new diagnosis of diabetes mellitus is being taught about foot care. What instruction should the nurse include?
- A. Apply lotion between the toes after bathing
- B. Wear shoes at all times
- C. Cut toenails in a rounded shape
- D. Inspect the feet weekly
Correct Answer: B
Rationale: The correct answer is to wear shoes at all times. This instruction is vital for clients with diabetes mellitus as it helps protect the feet and reduces the risk of injury. Option A is incorrect as applying lotion between the toes can increase moisture and the risk of fungal infections. Option C is incorrect as cutting toenails in a rounded shape may lead to ingrown toenails. Option D is also incorrect as inspecting the feet weekly is not sufficient for proper foot care in clients with diabetes mellitus.
A client scheduled for cataract surgery tells the nurse, 'I see just fine and have decided to cancel my surgery.' What should the nurse do?
- A. Proceed with the surgery as planned
- B. Document the refusal and inform the surgeon
- C. Explain the benefits of the surgery
- D. Respect the client's decision
Correct Answer: C
Rationale: In this scenario, the nurse should explain the benefits of the surgery to the client. By providing more information, the client may reconsider their decision after understanding the positive impact the surgery could have on their vision. Proceeding with the surgery against the client's wishes (Choice A) is not ethical and goes against the principle of autonomy. While documenting the refusal and informing the surgeon (Choice B) is important for the client's medical record, it is crucial to first try to educate the client about the benefits. Simply respecting the client's decision (Choice D) without attempting to provide more information may not be in the client's best interest.
During a focused assessment for a client with dysrhythmias, what indicates ineffective cardiac contractions?
- A. Increased heart rate
- B. Pulse deficit
- C. Elevated blood pressure
- D. Bounding pulse
Correct Answer: B
Rationale: A pulse deficit is a crucial finding in clients with dysrhythmias as it indicates ineffective cardiac contractions. A pulse deficit occurs when the apical heart rate is faster than the radial pulse rate, suggesting that some heartbeats are not generating a pulse. This can be a sign of serious heart conditions like atrial fibrillation or heart failure. The other options, such as an increased heart rate (choice A), elevated blood pressure (choice C), and bounding pulse (choice D), do not specifically indicate ineffective cardiac contractions and are not directly associated with dysrhythmias.
A client signed an informed consent form for surgery but has expressed doubts about the need for surgery. What should the nurse say?
- A. Reassure the client of the surgeon's skill
- B. The surgeon will answer your questions before surgery
- C. Tell the client surgery is necessary
- D. Encourage the client to seek a second opinion
Correct Answer: B
Rationale: The correct answer is B because the surgeon should address the client's doubts before surgery. Informed consent requires that the client fully understands the procedure. Choice A is incorrect because reassuring the client of the surgeon's skill does not address the client's doubts about the need for surgery. Choice C is incorrect because telling the client surgery is necessary may not address their concerns and could violate the principle of autonomy. Choice D is incorrect as the immediate concern is addressing the client's doubts before surgery, not necessarily seeking a second opinion.