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While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively.Which action should the nurse implement?
- A. Demonstrate the skill speaking slowly and using simple terms.
- B. Reassure the client that the skill is not difficult to learn.
- C. Reduce the stimuli in the area before continuing the teaching.
- D. Provide the client with step-by-step written instruction.
Correct Answer: C
Rationale: Sensory overload happens when an individual is getting more input from their senses than their brain can sort through and process. Therefore, reducing the stimuli in the area can help the client's brain to better process the information being taught.
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The nurse is caring for a client who has only months predicted to live. The client avoids questions regarding plans for care.What is the next approach for the nurse to use when discussing end of life issues with the client?
- A. Ask questions in a vague, nonspecific format.
- B. Get the most difficult questions over with first.
- C. Begin with questions that are less sensitive in nature.
- D. Share personal values to put the client at ease.
Correct Answer: C
Rationale: Nurses who provide end of life care are trained to communicate in a way that is concise, yet sensitive. A personalized approach is often taken to meet the unique communication needs of each patient and to recognize when a person may be in pain or distressed.
A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate.Which action should the nurse take to evaluate the client for urinary retention?
- A. Review the chart for number of voids over the last 24 hours.
- B. Evaluate the client for urinary incontinence.
- C. Scan the client's bladder after voiding.
- D. Palpate the suprapubic region for distention.
Correct Answer: C
Rationale: This will help determine if there is any residual urine left in the bladder after voiding.
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.
The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago.Which intervention should the nurse implement next?
- A. Ask the UAP to offer back rubs to the client.
- B. Reassess the client and the level of pain.
- C. Encourage the client to focus on taking deep breaths.
- D. Tell the client the medication needs more time to work.
Correct Answer: B
Rationale: The nurse should reassess the client's pain level and determine if additional interventions are needed to manage the pain.