Nokea
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.
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Which of the following dysrhythmias is the client displaying?
- A. First-degree atrioventricular block
- B. Complete heart block
- C. Premature atrial complexes
- D. Atrial fibrillation
Correct Answer: A
Rationale: The correct answer is A: First-degree atrioventricular block. This dysrhythmia is characterized by a delay in conduction at the atrioventricular node, causing a prolonged PR interval (>0.20 sec) on ECG. It is a benign condition and does not typically require treatment unless symptomatic. Choices B and D are more serious dysrhythmias that have different ECG patterns and clinical implications. Complete heart block (Choice B) presents with a lack of conduction between the atria and ventricles, leading to a slow ventricular rate. Atrial fibrillation (Choice D) is characterized by rapid, irregular atrial depolarizations without effective atrial contractions. Premature atrial complexes (Choice C) are early ectopic atrial beats that appear as abnormal P waves on ECG but do not cause significant conduction delays.
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 plan to take?
- A. Position the client on the affected side for 4 hr following the procedure
- B. Instruct the client to avoid coughing during the procedure
- C. Inform the client that he will be NPO for 6 hr prior to the procedure
- D. Place the client in the prone position during the procedure,
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to avoid coughing during the procedure. This is crucial because coughing can disrupt the procedure, leading to potential complications. Coughing can cause movement that may interfere with the accuracy of the procedure or cause injury to the client. Positioning the client on the affected side (A) for 4 hours following the procedure is not necessary and can lead to discomfort. Informing the client that they will be NPO for 6 hours prior to the procedure (C) may not be relevant depending on the type of procedure. Placing the client in the prone position during the procedure (D) can be risky and uncomfortable for the client.
A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?
- A. Act as a liaison between the facility and the media:
- B. Recommend to the provider specific acute care clients for discharge.
- C. Determine the medical needs of incoming clients through the emergency department
- D. Call in additional medical surgical unit nursing care staff.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: The nurse should plan to determine the medical needs of incoming clients through the emergency department during a mass casualty event to prioritize care based on severity. This action allows for efficient allocation of resources and timely treatment for those in critical condition. Acting as a liaison with the media (A) is not a priority during such emergencies. Recommending clients for discharge (B) is inappropriate as the focus should be on incoming patients. Calling in additional staff (D) may be necessary but determining medical needs is the immediate priority.
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?
- A. Initiate continuous bladder irrigation.
- B. Administer a fluid bolus
- C. Clamp the catheter tubing for 30 min.
- D. Obtain a urine specimen for culture and sensitive
Correct Answer: B
Rationale: The correct answer is B: Administer a fluid bolus. The dark yellow urine output at 25 mL/hr indicates concentrated urine and potential dehydration. Administering a fluid bolus would help improve hydration status and increase urine output. Continuous bladder irrigation (A) is not indicated as there is no indication of bladder obstruction. Clamping the catheter tubing (C) can lead to urinary retention and should not be done without a specific reason. Obtaining a urine specimen for culture (D) is important, but addressing the dehydration issue takes priority.