Nokea
Which response by the nurse is most therapeutic?
- A. Tell me about the visit with your significant other.
- B. I can see that you are feeling lonely.
- C. Would you like to talk for a while?
- D. What did you enjoy about your visit tonight?
Correct Answer: C
Rationale: This response shows that the nurse is willing to listen and provide support to the client. It also allows the client to decide if they want to talk and share their feelings.
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Prior to performing digital removal of a fecal impaction, what is the most important assessment for the nurse to perform?
- A. Abdominal girth.
- B. Breath sounds.
- C. Bowel sounds.
- D. Vital signs.
Correct Answer: D
Rationale: Prior to performing digital removal of a fecal impaction, it is important for the nurse to assess the client's vital signs. This includes checking the client's blood pressure, pulse rate, respiratory rate, and temperature. These measurements can provide important information about the client's overall health status and can help the nurse determine if it is safe to proceed with the procedure.
The nurse is teaching a client how to self-administer subcutaneous heparin injections.Which instruction should the nurse include?
- A. Inject in abdominal area at least 2 inches from the umbilicus.
- B. Rotate injections between the abdomen and gluteal areas.
- C. Massage the injection site to increase absorption.
- D. Expel the air in the prefilled syringe prior to injection.
Correct Answer: A
Rationale: Inject in abdominal area at least 2 inches from the umbilicus. When administering subcutaneous heparin injections, it is important to choose an injection site on either your tummy or outer areas of your left or right thigh. Your tummy is usually best as the injection site and it is important that you change the site each time.
How should the nurse document the finding of pain, numbness, and tingling sensations in the lower legs?
- A. Acute pain.
- B. Neuropathic pain.
- C. Visceral pain.
- D. Nociceptive pain.
Correct Answer: B
Rationale: The symptoms of pain, numbness, and tingling sensations in the lower legs are consistent with neuropathic pain. Neuropathic pain is a complex type of pain initiated or caused by a primary lesion or dysfunction in the nervous system.
The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions.Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?
- A. Shares the health history with case manager.
- B. Discusses diagnoses with the physical therapist.
- C. Provides a list of food allergies to nutritional services.
- D. Requests military records by phone.
Correct Answer: D
Rationale: Requesting military records by phone without the patient's consent would be a breach of confidentiality.
The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?
- A. Blood pressure.
- B. Respiratory rate.
- C. Temperature.
- D. Pulse rate.
Correct Answer: B
Rationale: If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation. Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation. Therefore, the nurse should obtain the respiratory rate first.