Nokea
While observing an unlicensed assistive personnel (UAP) providing a total bed bath for a confused and lethargic client, the nurse notes the UAP soaking the client's foot in a basin of warm water placed on the bed. What action should the nurse take?
- A. Remove the basin of water from the client's bed immediately
- B. Remind the UAP to dry between the client's toes completely
- C. Advise the UAP that this procedure may lead to skin damage
- D. Add skin cream to the basin of water while the foot is soaking
Correct Answer: B
Rationale: The correct action for the nurse to take in this situation is to remind the unlicensed assistive personnel (UAP) to dry between the client's toes completely. Failing to dry between the toes can lead to skin breakdown due to excessive moisture accumulation. Proper drying is essential to maintain skin integrity and prevent complications in the client's care. Removing the basin of water immediately may disrupt the care process and not address the root cause of the issue. Advising about potential skin damage is not as direct and actionable as reminding to dry between the toes. Adding skin cream to the water may not be appropriate without specific orders and can potentially worsen the situation by increasing moisture.
You may also like to solve these questions
The client reports still being unable to sleep a week after learning progressive muscle relaxation techniques. Which action should the nurse take first?
- A. Instruct the client to add regular exercise to the daily routine.
- B. Determine if the client has been keeping a sleep diary.
- C. Encourage the client to continue the routine until sleep is achieved.
- D. Ask the client to describe the routine currently followed.
Correct Answer: D
Rationale: The nurse should first assess the client's adherence to the original instructions. By asking the client to describe the routine, the nurse can evaluate if the technique is being correctly implemented before considering further interventions. This choice is correct as it focuses on assessing the client's current practice. Option A is incorrect as adding regular exercise may not address the issue with the relaxation technique. Option B is incorrect as determining if the client has been keeping a sleep diary does not directly address the efficacy of the relaxation technique. Option C is incorrect as blindly encouraging the client to continue may not be the best approach without understanding how the technique is being practiced.
A client is admitted with a diagnosis of fluid volume excess. Which intervention should the nurse include in the client's plan of care?
- A. Encourage increased fluid intake.
- B. Place the client in a high Fowler's position.
- C. Measure the client's intake and output.
- D. Restrict dietary sodium intake.
Correct Answer: D
Rationale: Restricting dietary sodium intake (D) is the most critical intervention for a client with fluid volume excess to prevent further fluid retention. Encouraging increased fluid intake (A) would exacerbate the issue by adding more fluid to the body. Placing the client in a high Fowler's position (B) is more relevant for respiratory issues than fluid volume excess. While measuring intake and output (C) is important for assessing fluid balance, restricting sodium intake is the priority as it helps manage fluid levels more effectively by reducing fluid retention.
The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. What should the nurse do first?
- A. Administer nasal oxygen at a rate of 5 L/min
- B. Help the client to lie back down in the bed
- C. Quickly pivot the client to the chair and elevate the legs
- D. Check the client's blood pressure and pulse
Correct Answer: D
Rationale: Before assisting the client out of bed, the nurse should first assess the client's blood pressure and pulse. This assessment is crucial to determine the client's physiological stability and readiness for ambulation. It ensures the client's safety during the transfer and helps prevent any potential complications that may arise from getting out of bed. Administering oxygen, lying the client back down, or quickly moving the client to a chair without assessing vital signs can compromise the client's safety and may lead to adverse outcomes.
When a student nurse is caught taking a copy of a client's medication administration record to help a friend prepare for the next day's clinical, what should the nurse respond first?
- A. Ask the nursing supervisor to meet with the student.
- B. Notify the student's clinical instructor of the situation.
- C. Ask the student if permission was obtained from the client.
- D. Explain that the records are hospital property and may not be removed.
Correct Answer: D
Rationale: The correct response when a student nurse is caught taking a copy of a client's medication administration record is to explain that the records are hospital property and cannot be removed. It is essential to educate the student about the confidentiality and security of patient information, emphasizing that even with the client's consent, such actions are unacceptable. Option A is not the immediate action needed, as addressing the student directly should come first. Option B involves notifying another party before addressing the student directly. Option C is incorrect because even if the client gave permission, patient records are confidential and cannot be shared without authorization.
The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?
- A. Encourage the client to increase ambulation in the room.
- B. Offer the client a high-carbohydrate snack for energy.
- C. Force fluids to thin the client's pulmonary secretions.
- D. Determine if pain is causing the client's tachypnea.
Correct Answer: D
Rationale: An increased respiratory rate can be a sign of various issues postoperatively, including pain. Assessing and managing pain is crucial as it can lead to tachypnea. Pain, anxiety, and fluid accumulation in the lungs can all contribute to an increased respiratory rate. Therefore, determining if pain is causing the tachypnea is the most important intervention to address the underlying cause. Encouraging ambulation, offering snacks, or forcing fluids are not the priority in this situation as pain assessment takes precedence in managing the increased respiratory rate.