*A 20-12 months-antique lady patron with a sizeable frame odor has refused to bathe for the
ultimate three days. She states, "I had been informed that it's far dangerous to wash in the
course of my duration." Which action should the nurse take first?*
A. Accept and report the consumer's desire to chorus from bathing.
B. Offer to give the customer a bed bathtub, heading off the perineal vicinity.
C. Obtain written brochures approximately menstruation to provide to the consumer.
D. Teach the significance of personal hygiene all through menstruation with the consumer. -
ANS-D. Teach the significance of private hygiene during menstruation with the consumer.
Rationale: Because a shower is most beneficial for the customer in phrases of hygiene, the
consumer need to get hold of coaching first, respecting any personal beliefs which include
cultural or spiritual values. After consumer teaching, the purchaser may additionally
nevertheless select alternative A or B. Brochures enhance the coaching.
*A sixty five-12 months-antique client who attends an adult daycare application and is
wheelchair cell has redness within the sacral region. Which training is maximum important for
the nurse to provide?*
A. "Take a vitamin complement tablet as soon as a day."
B. "Change positions within the chair regularly"
C. "Increase daily consumption of water or other oral fluids."
D. "Purchase a newer version wheelchair." - ANS-B. "Change positions in the chair frequently"
Rationale: The most vital coaching is to change positions often due to the fact stress is the
maximum full-size element associated with the improvement of pressure ulcers.
*A 75-12 months-old customer states to the nurse, "I am just not hungry anymore." The patron
has lost 10 pounds/4.Fifty three kg inside the past 4 months. Which snacks will the nurse
endorse to the client? (Select all that observe.)*
A. Nuts
B. Milkshakes
C. Chocolate candy bar
D. Peanut butter and crackers
E.Glass of complete fats milk - ANS-A. Nuts
B. Milkshakes
D. Peanut butter and crackers
E.Glass of complete fat milk
,Rationale: The nurse ought to advocate high calorie/high nutrition ingredients for this customer
who's by chance dropping weight. The sweet bar is high calorie, but empty in dietary price. The
last selections are excessive calorie/high vitamins.
*A 76-12 months-vintage purchaser has again from surgical treatment. The nurse plans on
reducing the danger of respiration compromise for this consumer. What will the nurse consist of
in this purchaser's plan of care? (Select all that apply.)*
A. Raise the pinnacle of the mattress to no less than a 45 ranges attitude.
B. Have the patron use an incentive spirometer 10 times every hour even as unsleeping.
C. Limit general fluid consumption to no more than one thousand mL/day.
D. Have the purchaser take a seat on the facet of the bed alternatively of getting up and on foot.
E. Ask the consumer to take deep breaths and cough 5 instances each hour whilst conscious. -
ANS-A. Raise the head of the mattress to no less than a 45 levels attitude.
B. Have the client use an incentive spirometer 10 times every hour while wide awake.
E. Ask the consumer to take deep breaths and cough five times every hour while conscious.
Rationale: As long because the customer is not on a fluid restriction, offer no less than 2000 mL
of fluid to hold the body properly hydrated and hold respiration secretions free. Ambulation is
fundamental for this patron. Sitting on the facet of the mattress isn't a substitute for ambulating.
Having the customer sit up enables make bigger the lungs. Taking deep breaths, via coughing
or incentive spirometry, enables expand the lungs and decrease atelectasis.
*A consumer turns into indignant at the same time as waiting for a supervised destroy to smoke
a cigarette outdoor and states, "I want to move outdoor now and smoke. It takes all the time to
get some thing carried out right here!" Which nursing motion is nice for this consumer?*
A. Encourage the consumer to apply a nicotine patch.
B. Reassure the customer that it is nearly time for some other spoil.
C. Have the client depart the unit with any other body of workers member.
D. Review the time table of outdoor breaks with the client. - ANS-D. Review the time table of
outside breaks with the consumer.
Rationale: The satisfactory nursing action is to study the time table of outside breaks and offer
concrete data approximately the agenda. Option A is contraindicated if the customer desires to
preserve smoking. Option B is inadequate to encourage a trusting courting with the patron.
Option C is preferential for this customer handiest and is inconsistent with unit regulations.
*A consumer has a nasogastric tube connected to low intermittent suction. When administering
medicines thru the nasogastric tube, which motion have 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-D. Turn off the intermittent suction tool
,Rationale: The nurse ought to first turn off the suction and then affirm placement of the tube in
the stomach earlier than instilling the medications. To prevent instant removal of the instilled
medicinal drugs and allow absorption, the tube ought to be clamped for a time frame before
reconnecting the suction.
*A purchaser in an extended-term care facility reviews to the nurse, "I have no longer had a
bowel motion in 2 days." What is the nurse's first movement?*
A. Instruct the caregiver to offer a pitcher of warm prune juice at mealtimes.
B. Notify the fitness care company and request a prescription for a large-quantity enema.
C. Assess the patron's clinical file to decide the client's regular bowel pattern.
D. Instruct the caregiver to boom the customer's fluids to 5 8-ounce glasses per day. - ANS-C.
Assess the customer's clinical report to determine the purchaser's ordinary bowel sample.
Rationale: This consumer might not routinely have a daily bowel movement, so the nurse must
first check this purchaser's ordinary bowel conduct earlier than trying any intervention. Options
A, B, or D can also then be carried out, if warranted.
*A client is giggling at a tv software while the nighttime nurse enters the room. The consumer
states, "My foot is hurting. I would love a ache pill." How have to the nurse respond?*
A. Ask the consumer to price the ache the usage of a 1 to ten scale.
B. Encourage the purchaser to wait till bedtime for the pill.
C. Attend to an acutely unwell client's needs first due to the fact this client is guffawing.
D. Instruct the consumer inside the use of deep respiratory sporting events for ache manage. -
ANS-A. Ask the patron to charge the pain the use of a 1 to 10 scale.
Rationale:Obtaining a subjective estimate of the ache experience by means of asking the client
to charge his ache allows the nurse decide which ache medicinal drug must be administered
and also offers a baseline for evaluating the effectiveness of the drugs. Medicating for pain must
not be delayed so that it may be used as a snooze medicine. Option C is judgmental. Option D
need to be used as an adjunct to ache medication, not as an alternative of medicine.
*A purchaser with frequent urinary tract infections (UTIs) asks the nurse to explain a chum's
advice about drinking a pitcher of juice day by day to prevent future UTIs. Which response is
exceptional for the nurse to offer?*
A. "Orange juice has diet C that deters bacterial increase."
B. "Apple juice is the most useful in acidifying the urine."
C. "Cranberry juice stops pathogens' adherence to the bladder."
D. "Grapefruit juice will increase absorption of maximum antibiotics." - ANS-C. "Cranberry juice
stops pathogens' adherence to the bladder."
Rationale: Cranberry juice continues urinary tract health by way of reducing the adherence of
Escherichia coli micro organism to cells in the bladder. Options A, B, and D have no longer been
proven to be as effective as cranberry juice in stopping UTIs.
*A client's blood stress analyzing is 156/94 mm Hg. Which action ought to the nurse take first?*
, A. Tell the client that the blood pressure is excessive and that the analyzing desires to be
confirmed via some other nurse.
B. Contact the health care issuer to record the reading and acquire a prescription for an
antihypertensive medicinal drug.
C. Replace the cuff with a bigger one to make certain an sufficient in shape for the consumer to
growth arm comfort.
D. Compare the modern studying with the client's previously documented blood stress readings.
- ANS-D. Compare the modern studying with the customer's previously documented blood
stress readings.
Rationale: Comparing this reading with preceding readings will provide records about what is
everyday for this customer; this action should be taken first. Option A would possibly
unnecessarily alarm the customer. Option B is untimely. Further evaluation is wanted to decide if
the studying is extraordinary for this client. Option C may want to falsely decrease the analyzing
and is not an appropriate procedure for acquiring a blood stress analyzing.
*A community sanatorium is starting a mental health offerings department. Which document
should the nurse use to increase the unit's nursing pointers?*
A. Americans with Disabilities 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-C. ANA's Scope and Standards of Nursing Practice
Rationale: The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing
serves to direct the philosophy and standards of psychiatric nursing practice. Options A and D
outline the patron's rights. Option B presents moral hints for nursing.
*A hospitalized purchaser has had trouble falling asleep for 2 nights, and is becoming irritable
and stressed. Which action by means of the nurse is nice?*
A. Determine the patron's common bedtime routine and include those rituals in the plan of care
as protection permits.
B. Instruct the UAP not to wake the consumer below any occasions at some point of the night
time.
C. Place a "Do Not Disturb" sign on the door and trade exams from every 4 to eight hours.
D. Encourage the client to keep away from ache medication all through the day, which would
possibly growth daytime napping. - ANS-A. Determine the consumer's regular bedtime recurring
and include these rituals within the plan of care as protection permits.
Rationale: Including recurring rituals that don't interfere with the customer's care or protection
might also permit the customer to fall asleep quicker and growth the first-rate of care. Options B,
C, and D lower the consumer's standard of care and compromise safety.
*A nurse is assigned to care for a close friend in the health center setting. Which motion ought
to the nurse take first whilst given the project?*
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