Nokea
Which is the best approach for the nurse to use when interviewing a client about sexuality/reproductive function?
- A. Ask questions in a vague, nonspecific format.
- B. Get the most difficult questions over with first.
- C. Share personal values to put the client at ease.
- D. Begin with questions that are less sensitive in nature.
Correct Answer: D
Rationale: Less sensitive questions build rapport.
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History and physical
A 78-year-old female was admitted three days ago with a stage 3 pressure wound at the coccyx. The wound was being cared for at home but has increased in severity from a stage 1 to a stage 3.
Nurses Notes
0800
Head-to-toe assessment complete. Vital signs stable. Pressure injury at the coccyx has anasept in the wound base covered with foam. Dressing clean, dry, and intact.
1200
Client returned from occupational therapy for hip pain. Vital signs stable. Wound dressing clean, dry, and intact.
1500
Client called out on the call light. Reported an incontinent episode. Perineal cleaning and linen
Flowsheet
Vital Signs
0800
• Temperature 98°F. (36.7 °C) orally
• Heart rate 82 beats/minute
• Respiratory rate 14 breaths/minute
. Blood pressure 136/62 mm Hg
1200
• Oxygen saturation 99% on room air
• Patri rating of 1 on 0 to 10 scale, located at соссух
• Temperature 98.4 °F. (36.9 °C) orally
• Heart rate 82 beats/minute
Orders
0830
Wound dressing change every Monday, Wednesday, Friday, and PRN:
Cleanse with normal saline and pat dry Apply anasept gel to wound base. Cover with foam dressing
The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.
- A. Gather materials to change soiled items only;
- B. Thoroughly clean wound using normal saline prior to redressing;
- C. Place sterile gauze directly on wound bed;
- D. Apply sterile gloves prior to changing;
- E. Apply sterile foam dressing over wound bed;
Correct Answer:
Rationale: Sterile technique and foam dressing promote healing.
The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?
- A. Impaired bed mobility.
- B. Fluid volume deficit.
- C. Bowel incontinence.
- D. Caregiver role strain.
Correct Answer: B
Rationale: Diarrhea risks dehydration, requiring urgent fluid management.
During the admission process, a client requests more information about advance directives. Which professional should the nurse recommend the client contact?
- A. Family attorney.
- B. Nurse manager.
- C. Hospice nurse.
- D. Chaplain.
Correct Answer: A
Rationale: Attorney provides legal guidance on advance directives.
The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?
- A. Power flush with 60 mL to remove mucous obstructions.
- B. Slowly irrigate catheter with saline using an infusion pump.
- C. Clamp the catheter for 30 minutes prior to irrigating.
- D. Use a sterile syringe to irrigate with 20 mL normal saline.
Correct Answer: B
Rationale: Slow irrigation safely clears clots and sediment.
The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?
- A. Develop self-awareness of the nurse's personal values to avoid imposing these values on the client.
- B. Challenge members of the healthcare team whose opinions differ from the wishes of the client.
- C. Educate the client about current nursing literature findings related to the client's ethical dilemma.
- D. Listen to the ethics committee discussions and then inform the client what actions should be taken.
Correct Answer: A
Rationale: Self-awareness prevents bias in advocacy.