Nokea
Which of the ff instructions should be given to the clients family if a client with impaired swallowing has to take solid medication?
- A. Mix the medication with food
- B. Use the liquid form of the medication
- C. Check with the physician or pharmacist before crushing or breaking tablets, or opening capsules
- D. Perform ROM exercises after the medication is administered
Correct Answer: C
Rationale: The correct answer is C because crushing or breaking tablets can alter the medication's effectiveness or cause harm. Step 1: Consult a physician or pharmacist ensures safety and effectiveness. Step 2: This step helps in determining if the medication can be safely altered for easier swallowing. Step 3: Using liquid form (B) may not always be an option. Mixing with food (A) can affect absorption. ROM exercises (D) are unrelated to medication administration.
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What discharge teaching is most important to help the patient who has had a splenectomy prevent infection?
- A. Avoid showering for 1 week.
- B. Sleep in a semi-fowler’s position.
- C. Receive vaccines against infection.
- D. Stay on antibiotics for life.
Correct Answer: C
Rationale: The correct answer is C: Receive vaccines against infection. Following a splenectomy, the patient is at an increased risk of infection due to the absence of the spleen's immune function. Vaccines help boost the body's immunity against specific pathogens, reducing the risk of infections. This is crucial for preventing post-splenectomy infections.
Now, let's analyze the other choices:
A: Avoid showering for 1 week - There is no evidence to support that avoiding showering would prevent infection after a splenectomy.
B: Sleep in a semi-fowler’s position - Positioning does not directly impact infection prevention post-splenectomy.
D: Stay on antibiotics for life - Long-term antibiotic use can lead to antibiotic resistance and is not recommended unless specifically indicated for a different reason.
The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?
- A. The patient’s room with the door closed
- B. The waiting area with the television turned off
- C. The patient’s room before administration of pain medication
- D. The waiting room while the occupational therapist is working on leg exercises
Correct Answer: B
Rationale: The correct answer is B: The waiting area with the television turned off. This setting provides a quiet environment, minimizing distractions for the patient with a hearing deficit. It allows the nurse to communicate effectively by speaking clearly and facing the patient directly. Option A is incorrect because a closed door may not be enough to reduce background noise. Option C is incorrect as pain medication may affect the patient's ability to concentrate. Option D is incorrect because the occupational therapist working on leg exercises may create additional noise and distractions.
A nurse is documenting the progress of a client who has been recovering from a myocardial infarction. Which of the following would be most appropriate to include in the evaluation?
- A. Client's vital signs and lab results from admission.
- B. Client reports walking 500 meters without chest pain.
- C. Physician notes on the client’s progress.
- D. Medications prescribed during hospitalization.
Correct Answer: B
Rationale: The correct answer is B because it directly reflects the client's progress in physical activity, a key indicator of recovery post-myocardial infarction. Walking 500 meters without chest pain shows improved cardiovascular function and exercise tolerance. Vital signs and lab results from admission (A) are important for initial assessment but not for ongoing evaluation. Physician notes (C) may provide insights but do not directly measure the client's progress. Medications prescribed (D) are important but do not reflect the client's specific improvement in physical activity.
A post-TURP patient experiences dribbling following removal of his catheter. Which action should the nurse take?
- A. Have him restrict fluid intake to 1000 mL/day
- B. Teach him to perform Kegel’s exercises 10 to 20 times per hour
- C. Reinsert the Foley catheter until he regains urinary control
- D. Reassure him that incontinence never lasts more than a few days
Correct Answer: B
Rationale: The correct answer is B: Teach him to perform Kegel's exercises 10 to 20 times per hour. This is the appropriate action because Kegel's exercises help strengthen the pelvic floor muscles, which can improve urinary control and reduce dribbling post-TURP. Restricting fluid intake (A) is not necessary and may lead to dehydration. Reinserting the Foley catheter (C) is not recommended as it can increase the risk of infection. Reassuring the patient (D) without providing any intervention is not addressing the issue. Teaching Kegel's exercises is the most effective and non-invasive approach to manage post-TURP dribbling.
Which of the following types of care plans is most likely to enable the nurse to take a holistic view of the client’s situation?
- A. Kardex
- B. Case management
- C. Critical pathways
- D. Concept map care plan
Correct Answer: D
Rationale: The correct answer is D: Concept map care plan. This type of care plan allows the nurse to visually represent the client's entire situation, including physical, emotional, and social aspects. By using interconnected concepts and relationships, the nurse can see the whole picture and identify potential interventions. Kardex (A) is a concise patient information summary, not comprehensive. Case management (B) focuses on coordinating services but may not capture the holistic view. Critical pathways (C) outline specific steps in care but may not address the client as a whole.