Nokea
When the nurse is assessing a client's cultural adaptation, which of the following statements is least sensitive to the client's needs?
- A. What are some of your favorite foods?'
- B. Describe any health problems in your past.'
- C. Please tell me how you would like to be addressed.'
- D. Your eyes look dark; is this normal for you?'
Correct Answer: D
Rationale: Commenting on the client's appearance (dark eyes) is insensitive and irrelevant to cultural adaptation, potentially making the client uncomfortable.
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The nurse is providing care to the client who has received medication therapy with tissue plasminogen activator. Which item should the nurse have available for use as part of standard nursing care for this client?
- A. Flashlight
- B. Pulse oximeter
- C. Suction equipment
- D. Occult blood test strips
Correct Answer: D
Rationale: Tissue plasminogen activator is a thrombolytic medication that is used to dissolve thrombi or emboli caused by thrombus. A frequent and potentially adverse effect of therapy is bleeding. The nurse monitors for signs of bleeding in clients receiving this therapy. Equipment needed by the nurse would include occult blood test strips to monitor for occult blood in the urine, stool, or nasogastric drainage. A flashlight may be used for pupil assessment as part of the neurological exam in the client who is neurologically impaired. Pulse oximeter and suction equipment would be needed if the client had evidence of respiratory problems.
While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. Which of the following should the nurse do next?
- A. Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.
- B. Ask the client to assume a side-lying position with the knees flexed.
- C. Perform massage vigorously at the level of the umbilicus if the fundus feels boggy.
- D. Place the client on a bedpan in case the uterine palpation stimulates the client to void.
Correct Answer: A
Rationale: This technique stabilizes the uterus during fundus assessment, preventing discomfort and ensuring accurate palpation.
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed ipratropium (Atrovent). The nurse should instruct the client to:
- A. Rinse the mouth after inhalation.
- B. Take the medication with meals.
- C. Avoid using the inhaler during an acute attack.
- D. Stop the medication if dizziness occurs.
Correct Answer: A
Rationale: Rinsing the mouth after ipratropium inhalation prevents oral irritation or infection.
A child's plan of care lists increasing protein intake as a goal. Which of the following foods that the child likes should the nurse encourage the child to eat?
- A. A bacon, lettuce, and tomato sandwich.
- B. Fruit-flavored yogurt.
- C. Nacho chips and salsa.
- D. Crackers with butter and jelly.
Correct Answer: B
Rationale: Fruit-flavored yogurt is a good source of protein, suitable for increasing protein intake in a child's diet.
A client has been diagnosed with viral hepatitis. Which of the following goals is most appropriate for the client?
- A. Achieve control of abdominal pains
- B. Increase activity levels gradually
- C. Reduce jaundice
- D. Prevent liver damage
Correct Answer: B
Rationale: Increasing activity levels gradually is an appropriate goal for viral hepatitis, as rest is needed initially but gradual return to activity supports recovery. Pain is less common, and jaundice or liver damage prevention are secondary.