A 20-12 months-vintage lady patron with a important frame smell has refused to shower for the
final 3 days. She states, "I were advised that it's miles dangerous to wash at some stage in my
period." Which movement have to the nurse take first?
A. Accept and report the patron's desire to refrain from bathing.
B. Offer to offer the consumer a mattress bathtub, warding off the perineal region.
C. Obtain written brochures approximately menstruation to provide to the customer.
D. Teach the significance of private hygiene for the duration of menstruation with the client. -
ANS-Answer: D
Because a shower is most useful for the purchaser in phrases of hygiene, the client need to
receive teaching first (D), respecting any private beliefs consisting of cultural or spiritual values.
After patron teaching, the client may additionally still choose (A or B). Brochures improve the
coaching (C).
A sixty five-year-antique client who attends an person daycare software and is
wheelchair-mobile has redness within the sacral area. Which instruction is most crucial for the
nurse to provide?
A. Take a nutrition supplement pill as soon as a day.
B. Change positions inside the chair at least each hour.
C. Increase every day intake of water or other oral fluids.
D. Purchase a more recent version wheelchair. - ANS-Answer: B
The most crucial coaching is to alternate positions frequently (B) due to the fact stress is the
most sizeable aspect associated with the improvement of strain ulcers. Increased diet and fluid
intake (A and C) can also be beneficial promote recovery and decrease further chance. (D) is an
intervention of ultimate inn because this may be very costly for the patron.
A patron becomes irritated even as looking ahead to a supervised break to smoke a cigarette
out of doors and states, "I need to head out of doors now and smoke. It takes for all time to get
something carried out right here!" Which intervention is great for the nurse to put in force?
A. Encourage the patron to apply a nicotine patch.
B. Reassure the consumer that it's far nearly time for any other destroy.
C. Have the patron depart the unit with every other personnel.
D. Review the agenda of outdoor breaks with the consumer. - ANS-Answer: D
The quality nursing movement is to check the agenda of out of doors breaks (D) and provide
concrete facts about the time table. (A) is contraindicated if the client desires to maintain
smoking. (B) is inadequate to encourage a trusting courting with the consumer. (C) is
preferential for this customer handiest and is inconsistent with unit regulations.
A purchaser has a nasogastric tube linked to low intermittent suction. When administering
medicinal drugs via the nasogastric tube, which action need to the nurse do first?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
,D. Turn off the intermittent suction tool. - ANS-Answer: D
The nurse have to first flip off the suction (D) and then verify placement of the tube inside the
belly (B) before instilling the medications (C). To prevent immediate elimination of the instilled
medicines and allow absorption, the tube have to be clamped for a time period (A) earlier than
reconnecting the suction.
A purchaser has a nursing diagnosis of Altered sleep styles related to nocturia. Which
purchaser preparation is essential for the nurse to offer?
A. Decrease intake of fluids after the night meal.
B. Drink a tumbler of cranberry juice each day.
C. Drink a pitcher of heat decaffeinated beverage at bedtime.
D. Consult the health care provider approximately a snoozing tablet. - ANS-Answer: A
Nocturia is urination at some stage in the night. (A) is beneficial to decrease the production of
urine, consequently decreasing the need to void at night time. (B) enables prevent bladder
infections. (C) may additionally promote sleep, however the fluid will contribute to nocturia. (D)
may additionally result in urinary incontinence if the purchaser is sedated and does not wake up
to void.
A patron in a protracted-time period care facility reports to the nurse that he has no longer had a
bowel motion in 2 days. Which intervention must the nurse enforce first?
A. Instruct the caregiver to offer a tumbler of warm prune juice at mealtimes.
B. Notify the fitness care provider and request a prescription for a huge-quantity enema.
C. Assess the patron's clinical report to determine the client's regular bowel pattern.
D. Instruct the caregiver to boom the patron's fluids to 5 eight-ounce glasses per day. -
ANS-Answer: C
This patron may not mechanically have a every day bowel movement, so the nurse should first
investigate this customer's normal bowel conduct before attempting any intervention (C). (A, B,
or D) can also then be implemented, if warranted.
A client's blood strain studying is 156/94 mm Hg. Which motion need to the nurse take first?
A. Tell the client that the blood strain is excessive and that the studying needs to be established
with the aid of any other nurse.
B. Contact the fitness care company to record the studying and obtain a prescription for an
antihypertensive medication.
C. Replace the cuff with a larger one to ensure an enough healthy for the customer to growth
arm comfort.
D. Compare the contemporary analyzing with the consumer's formerly documented blood
pressure readings. - ANS-Answer: D
Comparing this reading with previous readings (D) will provide facts approximately what's
regular for this client; this action must be taken first. (A) would possibly unnecessarily alarm the
purchaser. (B) is premature. Further evaluation is needed to determine if the analyzing is
atypical for this patron. (C) may want to falsely decrease the analyzing and isn't always the
appropriate process for obtaining a blood strain analyzing.
A network sanatorium is commencing a mental fitness offerings department. Which document
need to the nurse use to develop the unit's nursing tips?
A. Americans with Disability Act of 1990
B. ANA Code of Ethics with Interpretative Statements
, C. ANA's Scope and Standards of Nursing Practice
D. Patient's Bill of Rights of 1990 - ANS-Answer: C
The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing (C) serves to
direct the philosophy and requirements of psychiatric nursing exercise. (A and D) define the
consumer's rights. (B) gives moral suggestions for nursing.
A woman purchaser with frequent urinary tract infections (UTIs) asks the nurse to give an
explanation for her pal's advice approximately drinking a tumbler of juice day by day to save you
destiny UTIs. Which response is high-quality for the nurse offer?
A. Orange juice has nutrition C that deters bacterial increase.
B. Apple juice is the maximum useful in acidifying the urine.
C. Cranberry juice stops pathogens' adherence to the bladder.
D. Grapefruit juice increases absorption of maximum antibiotics. - ANS-Answer: C
Cranberry juice (C) keeps urinary tract fitness by using lowering the adherence of Escherichia
coli micro organism to cells inside the bladder. (A, B, and D) have no longer been shown to be
as powerful as cranberry juice (C) in preventing UTIs.
A female nurse is assigned to care for a near pal, who says, "I am involved that pals will find out
about my prognosis." The nurse tells her buddy that legally she need to protect a consumer's
confidentiality. Which resource describes the nurse's legal responsibilities?
A. Code of Ethics for Nurses
B. State Nurse Practice Act
C. Patient's Bill of Rights
D. ANA Standards of Practice - ANS-Answer: B
The State Nurse Practice Act (B) contains felony necessities for the protection of client
confidentiality and the outcomes for breaches in confidentiality. (A) outlines ethical standards for
nursing care however does no longer encompass legal tips. (C and D) describe expectancies
for nursing practice but do now not cope with prison implications.
A hospitalized consumer has had issue falling asleep for two nights and is turning into irritable
and restless. Which action by the nurse is exceptional?
A. Determine the patron's normal bedtime recurring and include these rituals inside the plan of
care as safety permits.
B. Instruct the UAP no longer to wake the purchaser beneath any situations at some point of the
night time.
C. Place a "Do Not Disturb" sign up the door and trade tests from every four to each 8 hours.
D. Encourage the purchaser to avoid pain medication at some stage in the day, which may
increase daylight drowsing. - ANS-Answer: A
Including routine rituals that do not intervene with the client's care or protection may additionally
permit the patron to nod off faster and increase the fine of care (A). (B, C, and D) lower the
client's popular of care and compromise protection.
A male purchaser is giggling at a tv software with his wife while the night nurse enters the room.
He says his foot is hurting and he would love a ache pill. How have to the nurse respond?
A. Ask him to price his pain on a scale of 1 to 10.
B. Encourage him to attend till bedtime so the tablet can help him sleep.
C. Attend to an acutely ill patron's wishes first because this patron is giggling.
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