Nokea
Which of the following information should the nurse plan to include in the teaching?
- A. Apply petroleum jelly to soothe the mucous membranes
- B. Use synthetic fabrics for the client’s bedding
- C. Clean the equipment with an alcohol-based cleaning product.
- D. Avoid using nail polish remover around the client.
Correct Answer: D
Rationale: The correct answer is D: Avoid using nail polish remover around the client. This is important because nail polish remover contains harsh chemicals that can be harmful if inhaled or absorbed through the skin, especially for clients with compromised health conditions. Applying petroleum jelly (choice A) may not be recommended as it can trap bacteria and cause infection. Using synthetic fabrics for bedding (choice B) may not be ideal as natural fibers are more breathable and comfortable. Cleaning equipment with alcohol-based products (choice C) may not be suitable as it can be irritating to sensitive skin. Therefore, choice D is the best option for the client's safety and well-being.
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A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has epidural analgesia and weakness in the lower extremities
- B. A client who has a hip fracture and a new onset of tachypnea
- C. A client who has sinus arrhythmia and is receiving cardiac monitoring
- D. A client who has diabetes mellitus and an HbA1c of 6.8%
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client with a hip fracture and new onset of tachypnea first. Tachypnea in this client could indicate a potential complication such as a pulmonary embolism, which is a life-threatening condition requiring immediate intervention. Assessing this client first allows for prompt identification and management of any emergent issues. Clients with epidural analgesia and lower extremity weakness (choice A) may indicate a neurological concern but are not as urgent as tachypnea in a client with a hip fracture. Sinus arrhythmia with cardiac monitoring (choice C) and diabetes mellitus with an HbA1c of 6.8% (choice D) do not present immediate life-threatening situations that require immediate assessment compared to the client with a hip fracture and tachypnea.
Which of the following actions should the nurse expect from the leader during the session?
- A. The leader allows the group to discuss whatever they would like to regarding their medications
- B. The leader encourages group members to remain silent until questions are called for
- C. The leader has group members vote on what they would like to learn about during the session.
- D. The leader lectures about medication adverse effects to the group members.
Correct Answer: A
Rationale: The correct answer is A. The leader should allow the group to discuss whatever they would like regarding their medications to encourage active participation and engagement. This approach promotes a patient-centered discussion, empowers group members to share their experiences, concerns, and questions, and fosters a supportive and collaborative learning environment. This helps to address individual needs and promote a deeper understanding of medication management.
Choice B is incorrect because it inhibits open communication and stifles group participation. Choice C is incorrect as it may not address the specific needs of the group and may limit the discussion to only popular topics. Choice D is incorrect as it is a passive approach and does not promote active engagement or address individual concerns.
Which of the following actions should the nurse Include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
- A. Use a face shield with a mask when providing care to the client.
- B. Tell the client.You seem to be very upset.""
- C. Engage the panic alarm:
- D. Initiate seclusion protocol
Correct Answer: B
Rationale: The correct answer is B because acknowledging the client's emotions can help de-escalate the situation. By stating, "You seem to be very upset," the nurse shows empathy and understanding, which can help the client feel heard and validated. Using a face shield, engaging the panic alarm, or initiating seclusion protocol are not appropriate actions in this scenario as they do not address the client's emotional state or help in calming them down. Face shield and panic alarm are more related to safety precautions, while seclusion protocol should only be considered as a last resort for safety reasons. Therefore, choice B is the most appropriate action for interacting with a client who is aggravated, pacing, and speaking loudly.
Which of the following findings should the nurse expect?
- A. The client is oriented times three
- B. The client opens eyes to sound.
- C. The client is unable to obey commands.
- D. The client withdraws from pain
Correct Answer: A
Rationale: The correct answer is A: The client is oriented times three. This indicates that the client is alert and aware of person, place, and time. This finding is crucial in assessing the client's mental status and cognitive function. Opening eyes to sound (B) is a basic response but does not indicate orientation. Inability to obey commands (C) suggests altered mental status. Withdrawing from pain (D) may indicate a physical reflex rather than cognitive function. Overall, being oriented times three is the most comprehensive assessment of mental alertness and cognitive function.
A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
- A. Evaluate the client's ability to help with repositioning
- B. Reposition the client without the use of assistive devices.
- C. Raise the side rails on both sides of the client's bed during repositioning.
- D. Discuss the client's preferences for determining a repositioning schedule.
Correct Answer: A
Rationale: The correct answer is A: Evaluate the client's ability to help with repositioning. This is crucial as it assesses the client's capability and involvement in the process, promoting independence and preventing complications. Choice B is incorrect as assistive devices may be necessary for safety. Choice C is incorrect as raising side rails can limit access and may not be needed. Choice D is incorrect as discussing preferences is important but not directly related to repositioning.