Nokea
Which of the following instructions should the nurse include?
- A. Perform chest percussion and postural drainage at least twice daily.
- B. Restrict intake of foods that contain gluten.
- C. Administer pancreatic enzymes on an empty stomach.
- D. Use a nebulizer to administer a bronchodilator fallowing airway clearance therapy.
Correct Answer: A
Rationale: The correct answer is A: Perform chest percussion and postural drainage at least twice daily. Chest percussion and postural drainage are essential airway clearance techniques for patients with cystic fibrosis to help mobilize and clear mucus from the lungs. Performing these techniques at least twice daily helps to prevent mucus buildup, reduce the risk of infections, and improve lung function. Restricting gluten intake (B) is not specific to cystic fibrosis management. Administering pancreatic enzymes on an empty stomach (C) is important for patients with cystic fibrosis to aid in digestion, but it is not directly related to chest physiotherapy. Using a nebulizer after airway clearance therapy (D) may be beneficial, but the primary focus should be on chest physiotherapy as the initial intervention for mucus clearance.
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Which of the following actions should the nurse take? Select all that apply.
- A. Have a second nurse confirm the information on the blood label
- B. Insert a large bore IV catheter
- C. Witness the client signing a consent for transfusion.
- D. Flush the transfusion tubing with dextrose SM in water.
- E. Explain to the client that transfusion reactions are not serious
Correct Answer: A,B
Rationale: The correct actions are A and B. A second nurse confirming the information on the blood label ensures accuracy and prevents errors. Inserting a large bore IV catheter allows for rapid transfusion and prevents complications. Choice C ensures informed consent but is not directly related to the transfusion process. Choice D is incorrect because dextrose cannot be used to flush transfusion tubing. Choice E is incorrect as it provides inaccurate information to the client.
A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?
- A. Soak feet twice daily.
- B. Round the edges of toenails when trimming
- C. Use moisturizing lotion between the toes.
- D. Wear clean cotton socks every day.
Correct Answer: D
Rationale: The correct answer is D: Wear clean cotton socks every day. This instruction is crucial for diabetic foot care as it helps prevent moisture buildup, reduces the risk of infections, and maintains proper foot hygiene. Clean cotton socks minimize friction, provide cushioning, and promote good circulation.
Rationale for other choices:
A: Soaking feet twice daily can lead to dry skin, increasing the risk of skin breakdown and infection.
B: Rounding the edges of toenails can cause injury and increase the risk of ingrown toenails.
C: Using moisturizing lotion between the toes can create a moist environment, promoting fungal growth and skin maceration.
Which of the following actions should the nurse take first?
- A. Determine the client's Glasgow Coma Scale score
- B. Insert an indwelling urinary catheter for the client.
- C. Administer mannitol IV bolus to the client
- D. Prepare the client for an MRI of the brain.
Correct Answer: A
Rationale: The correct answer is A: Determine the client's Glasgow Coma Scale (GCS) score. This is the priority action as it helps assess the client's level of consciousness and neurological status quickly. It guides further interventions and treatment decisions. Inserting an indwelling urinary catheter (B) or administering mannitol IV bolus (C) may be needed but assessing neurological status comes first. Preparing for an MRI (D) is important but not the initial step.
A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the nurse plan to use during the group session?
- A. Encourage clients to establish a timeline for their own grieving process.
- B. Initiate a discussion with clients about ways to cope with changes in family dynamics.
- C. Assist clients in identifying ways suicide could have been prevented
- D. Discourage clients from sharing negative aspects of their relationship with the deceased person
Correct Answer: B
Rationale: The correct answer is B: Initiate a discussion with clients about ways to cope with changes in family dynamics. This is the most appropriate strategy as it addresses the immediate impact of the suicide on family dynamics and helps clients develop coping mechanisms. Discussing coping strategies can empower clients to navigate the difficult changes they are facing.
A: Encouraging clients to establish a timeline for their own grieving process may not be helpful as each individual grieves differently and timelines can vary significantly.
C: Assisting clients in identifying ways suicide could have been prevented may lead to feelings of guilt and self-blame, which can be harmful to the healing process.
D: Discouraging clients from sharing negative aspects of their relationship with the deceased person can hinder the expression of emotions and the processing of complex feelings related to the loss.
For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
- A. Document the blood product transfusion in the client's medical record.
- B. Stay with the client for the first 15 min of the transfusion
- C. Titrate the rate of infusion to maintain the client's blood pressure at least 91/60 mm. Hg
- D. Obtain the first unit of packed RBCS from the blood bank.
- E. Start an IV bolus of lactated Ringers solution.
Correct Answer: A,B,D
Rationale: [A: 1, B: 1, C: 0, D: 1, E: 0, F: , G: ]
- A: Documenting blood product transfusion is crucial for legal and tracking purposes.
- B: Staying with the client ensures immediate response to any adverse reactions.
- C: Titration of infusion rate for BP is not within nursing scope without physician order.
- D: Obtaining packed RBCs precedes transfusion to verify compatibility.
- E: Starting IV bolus of LR is not indicated as it is unrelated to the transfusion process.