Nokea
When planning home care for a 72-year-old client with osteomyelitis requiring a 6-week course of intravenous antibiotics, what is the most important action by the nurse?
- A. Investigating the client's insurance coverage for home IV antibiotic therapy
- B. Determining if there are adequate hand washing facilities in the home
- C. Assessing the client's ability to participate in self-care and/or the reliability of a caregiver
- D. Selecting the appropriate venous access device
Correct Answer: C
Rationale: Assessing the client's ability to participate in self-care or evaluating the reliability of a caregiver is crucial in ensuring adherence to the treatment plan. This action helps determine if the client can manage the intravenous antibiotics at home independently or if assistance is needed. Investigating insurance coverage, ensuring hand washing facilities, and selecting the venous access device are important aspects of care but assessing the client's ability for self-care and caregiver reliability takes precedence to promote treatment success and safety.
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A healthcare provider is witnessing a client sign an informed consent form for surgery. Which of the following describes what the healthcare provider is affirming by this action?
- A. The signature on the preoperative consent form is the client's
- B. The client understands the risks of the surgery
- C. The client is aware of all postoperative care instructions
- D. The client has no further questions about the surgery
Correct Answer: A
Rationale: The correct answer is A. When a healthcare provider witnesses a client signing an informed consent form for surgery, they are affirming that the signature on the form belongs to the client. This is crucial for ensuring patient autonomy and informed decision-making. Choices B, C, and D are incorrect because while it is important for the client to understand the risks of surgery, be aware of postoperative care instructions, and have an opportunity to ask questions, these elements are not specifically affirmed by the healthcare provider witnessing the signature.
The LPN/LVN is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which observation indicates that the client is experiencing oxygen toxicity?
- A. Nasal congestion
- B. Cough
- C. Sore throat
- D. Fatigue
Correct Answer: C
Rationale: The correct answer is 'C: Sore throat.' Oxygen toxicity can manifest with symptoms like a sore throat, cough, chest pain, difficulty breathing, and fatigue. However, a sore throat can be an early indicator of oxygen toxicity and should prompt immediate attention. Nasal congestion, cough, and fatigue are not specific indicators of oxygen toxicity but could be related to other factors in a client with COPD receiving oxygen therapy.
A client scheduled for abdominal surgery reports being worried. Which of the following actions should the nurse take?
- A. Offer information on a relaxation technique and ask if the client is interested in trying it.
- B. Request a social worker to see the client to discuss meditation.
- C. Attempt to use biofeedback techniques with the client.
- D. Tell the client many people feel the same way before surgery and to think of something else.
Correct Answer: A
Rationale: Offering relaxation techniques addresses the client's immediate concern by providing a proactive approach to managing anxiety. It shows empathy and offers a practical solution. Requesting a social worker for meditation (Choice B) may not be the most direct response to the client's immediate worry. Attempting biofeedback (Choice C) may not be suitable without the client's interest or consent. Telling the client to think of something else (Choice D) dismisses the client's feelings and does not provide constructive support.
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?
- A. Perform hand hygiene
- B. Identify the client using two identifiers
- C. Prepare the sterile field
- D. Don sterile gloves
Correct Answer: A
Rationale: Performing hand hygiene is essential before any direct patient care procedure to prevent the spread of infection. Proper hand hygiene helps reduce the risk of introducing harmful microorganisms to the client, especially when dealing with a procedure like tracheostomy care. Identifying the client, preparing the sterile field, and donning sterile gloves are all important steps in tracheostomy care, but hand hygiene precedes them to maintain asepsis and ensure patient safety.
The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements?
- A. The injury is expected to heal quickly because of thin periosteum.
- B. In some instances the result is a retarded bone growth.
- C. Bone growth is stimulated in the affected leg.
- D. This type of injury shows more rapid union than that of younger children.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.