Nokea
Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to help a client ambulate for the first time after a colon resection?
- A. Have the client sit on the side of the bed before helping the client to walk.
- B. If the client is dizzy ask the client to take some slow, deep breaths.
- C. Help the client to walk in the room as often as the client wishes.
- D. When you help the client to walk, ask if any pain occurs.
Correct Answer: A
Rationale: This statement gives clear directions to the UAP about the task and is most closely associated with the information provided in the stem that this is the client's first time out of bed after surgery.
You may also like to solve these questions
A young adult patient constantly seeks attention from the nurses, stomping away from the nurses’ station and pouting when her requests are refused.
- A. What is the most appropriate response by the nurse to a young adult patient exhibiting attention-seeking behavior?
- B. Have the patient establish trust with one staff person with whom therapeutic interventions should occur.
- C. Give the patient unsolicited attention when she is not exhibiting the unacceptable behaviors.
- D. Ignore the patient when she exhibits attention-seeking behavior.
- E. Rotate the staff so the patient will learn to relate to more than one nurse.
Correct Answer: B
Rationale: Rewarding non-attention-seeking behaviors with unsolicited attention reinforces positive behavior. Ignoring the patient or rotating staff does not address the behavior constructively, and assigning one staff member reduces consistency in approach.
What is the most important consideration when teaching parents how to reduce risks in the home?
- A. Age and knowledge level of the parents
- B. Proximity to emergency services
- C. Number of children in the home
- D. Age of children in the home
Correct Answer: D
Rationale: Age of children in the home. Safety measures must be tailored to the developmental stage of the children.
A 56-year-old man is visiting the doctor for the first time in seven years for treatment for an infected finger. The office nurse wants him to make an appointment for a physical. The nurse knows that he does not understand the importance of a physical when he makes which statement?
- A. I know my blood sugar and weight should be monitored.'
- B. I am healthy. If I wasn't, I'd have some problems.'
- C. I don't smoke and I exercise daily.'
- D. I understand that checking my blood pressure is important.'
Correct Answer: B
Rationale: Assuming health without symptoms dismisses the need for preventive screenings, indicating a lack of understanding of physicals.
A postoperative client has returned to his room from the surgical recovery area. The client is sleeping, and the nurse notes that the client is disoriented when aroused.
Which of the following actions, if taken by the nurse, is BEST?
- A. Place the call bell within the client's reach.
- B. Stay with the client until he is totally oriented.
- C. Restrain all four extremities until the client is oriented.
- D. Elevate the side rails until the client is fully awake.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not the safety action (2) unnecessary to stay with the client, especially while he is sleeping (3) restraints are unnecessary at this time (4) correct-side rails should always be elevated for any disoriented client
A client has a total laryngectomy with a permanent tracheostomy.
Which of the following would be necessary for the nurse to consider regarding the client's nutrition?
- A. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented.
- B. The client will be unable to maintain any PO intake as long as he has a tracheotomy in place.
- C. Nutritional and/or gastric feedings will not be attempted for approximately three weeks to decrease the incidence of aspiration.
- D. Since the client is dependent on the ventilator, nutritional intake will be delayed.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area (2) although the client has permanent tracheotomy, will be able to eat normally after area has healed (3) nutritional intake will begin when bowel sounds return and client can tolerate intake (4) client is not dependent on ventilator