Nokea
Which of the following actions should the nurse take?
- A. Place the client's hand in warm water.
- B. Perform in-and-out catheterization.
- C. Encourage the client to void in the shower.
- D. Apply fundal pressure to stimulate urination.
Correct Answer: C
Rationale: The correct action is C: Encourage the client to void in the shower. This option promotes relaxation and can help facilitate urination. Warm water can help relax the muscles and promote voiding without invasive procedures like catheterization (B) or fundal pressure (D), which can be uncomfortable and potentially harmful. Voiding in the shower also maintains privacy and dignity for the client. Choices E, F, and G are not relevant to promoting urination.
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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Anticipate administering prescribed immunosuppressant medications
- B. Ensure that client has intake of at least 200 ml/hr
- C. Encourage client to avoid direst sunlight
- D. Initiate contact precautions
- E. Prepare client for light therapy
- F. Sickle cell crisis
- G. Psoriasis
Correct Answer: B,E
Rationale: Systemic lupus erythematosus is indicated by the lab results and symptoms.
Which statement should the nurse include in the teaching?
- A. The test should be performed after your baby is 24 hours old.
- B. Genetic screening is only necessary if there is a family history of genetic disorders.
- C. Your baby cannot eat before the genetic screening test.
- D. If the first test is abnormal, no further testing is needed.
Correct Answer: A
Rationale: The correct answer is A because it accurately states the timing for performing the genetic screening test, which should be after the baby is 24 hours old to ensure accurate results. Choice B is incorrect because genetic screening may be recommended for all newborns, not just those with a family history. Choice C is incorrect because babies can eat before the test. Choice D is incorrect as further testing may be required if the initial results are abnormal.
Which of the following torts should the charge nurse identify as having occurred?
- A. Assault
- B. Battery
- C. False imprisonment
- D. Negligence
Correct Answer: A
Rationale: The charge nurse should identify assault as having occurred. Assault is the intentional act that causes a person to fear they will be harmed. In this case, if a healthcare provider threatens a patient with a procedure without their consent, it constitutes assault. Battery, on the other hand, is the intentional harmful or offensive touching of a person without consent. False imprisonment involves restraining a person against their will, which is not described in the scenario. Negligence refers to a failure to exercise reasonable care, and it does not apply here as the situation involves intentional actions.
Which of the following responses should the nurse make?
- A. Tell me what concerns you about the bedpan
- B. Make sure to use nearby furniture to support yourself when walking to the bathroom.
- C. I will have the physical therapist ambulate you to the bathroom.
- D. You have to use the bedpan for your own safety.
Correct Answer: A
Rationale: The correct answer is A: "Tell me what concerns you about the bedpan." This response demonstrates active listening and empathy, allowing the nurse to understand the patient's specific worries or fears. It promotes patient-centered care by addressing the individual's needs. Other options lack this patient-centered approach: B assumes the patient can walk, C delegates without assessing the patient's concerns, and D is directive and dismissive of the patient's feelings.
Which of the following actions should the nurse plan to take?
- A. Place the clients head of bed flat
- B. apply heat to the client's abdomen
- C. keep the client on NPO status
- D. administer A laxative to the client
Correct Answer: C
Rationale: The correct answer is C: keep the client on NPO status. This is the correct action as it means "nothing by mouth," which is often necessary before certain medical procedures or surgeries to prevent aspiration. Choice A is incorrect as elevating the head of the bed reduces the risk of aspiration. Choice B is incorrect as heat application may not be indicated and could potentially worsen the client's condition. Choice D is incorrect as administering a laxative may not be appropriate without a proper assessment.