Nokea
Which are appropriate examples of cost-effective care? Select all that apply.
- A. Considering the inside of the sterile glove wrapper as a small sterile field
- B. Donning clean, rather than sterile, gloves to remove a client’s dressing
- C. Returning opened, unused supplies from a client’s room to the central supply room
- D. Reusing a tourniquet for multiple clients unless it is visibly soiled
- E. Using remaining sterile saline in a bottle opened 48 hours ago before discarding
Correct Answer: A,B
Rationale: Using the glove wrapper as a sterile field and clean gloves for dressing removal reduce waste without compromising safety. Returning supplies, reusing tourniquets, and using old saline risk contamination or infection.
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A client who is blind is admitted to the hospital for surgery tomorrow. The client is able to get out of bed and eat until midnight. Which nursing action is most appropriate?
- A. Describe the surroundings and the objects in the room to the client.
- B. Put up the side rails and have the client ask for help when getting out of bed for any reason.
- C. Describe the voices of the personnel to the client.
- D. Remove objects such as water pitchers and glasses from the immediate vicinity.
Correct Answer: A
Rationale: Describing surroundings aids orientation and safety for a blind client, promoting independence. Side rails, voice descriptions, or removing objects are less helpful.
The nurse is evaluating how a client who has a halo brace is reacting to this change in his body image. Which statement by the client indicates a need for additional support in adjusting to the brace?
- A. I shall avoid going out in public since I may bump into people.'
- B. I don't mind that people look at me.'
- C. I told my grandchildren that this looks like a space helmet.'
- D. I like to sleep in the reclining chair that we have.'
Correct Answer: A
Rationale: Avoiding public interaction suggests poor adjustment to the halo brace, indicating a need for support to address body image concerns.
The nurse in the mental health unit observes a client hitting the wall repeatedly with the hands after an upsetting family therapy session. The nurse should recognize that the client is exhibiting which of the following defense mechanisms?
- A. projection
- B. displacement
- C. rationalization
- D. reaction formation
Correct Answer: B
Rationale: Defense mechanisms are unconscious mental processes used to protect individuals from uncomfortable thoughts, internal conflicts, and external stresses. Defense mechanisms may be therapeutic to clients with anxiety. However, with excessive use, defense mechanisms may become notherapeutic because they involve a degree of self-deception and reality distortion that can result in poor interpersonal relationships, irrational behavior, and decreased productivity.
The nurse is reinforcing teaching with a client who has a new prescription for sublingual nitroglycerin. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I am able to take nitroglycerin with my prescribed vardenafil
- B. I will stop taking nitroglycerin if I experience a headache or flushing
- C. I can keep a few nitroglycerin tablets in a plastic bag in case I need them while I am away from home
- D. I should take 1 nitroglycerin tablet every 5 minutes, up to 3 doses, if I am experiencing chest pain
Correct Answer: D
Rationale: Many clients lack knowledge about the proper administration, storage, and side effects of nitroglycerin (NTG). Client teaching can prevent many emergency department visits for chest pain caused by stable angina. Clients should be taught to take 1 tablet every 5 minutes, up to 3 doses. Emergency medical services should be called if pain does not improve or worsens 5 minutes after the first tablet is taken. Previously, clients were taught to call after the third dose was taken, but new evidence suggests this causes a significant delay in treatment
The nurse checks the lab values of a newly admitted client. RBC: 4.0 million/mm³, WBC: 1500/mm³, Platelets: 40,000/mm³. What nursing actions are indicated because of these lab values?
- A. Keep the client on bed rest and protective isolation.
- B. Plan for protective isolation and do not give injections.
- C. Keep the client on bed rest and avoid trauma.
- D. There are no special nursing actions indicated.
Correct Answer: B
Rationale: Low WBC (neutropenia) requires protective isolation, and low platelets (thrombocytopenia) contraindicate injections to prevent bleeding and infection.