Nursing Elites

1. A client has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should be administered to soften the feces?

• A. Oil retention
• B. Soapsuds
• C. Saline
• D. Hypertonic

Correct answer: A

Rationale: An oil retention enema is the most appropriate choice to soften and lubricate the feces before digital removal. Oil retention enemas help in making the stool easier to remove digitally due to their lubricating properties. Soapsuds, saline, and hypertonic enemas are not specifically designed to soften feces and are used for different purposes. Soapsuds enemas are used for cleansing, saline enemas for bowel evacuation, and hypertonic enemas for bowel distension in preparation for diagnostic procedures.

2. The client is receiving discharge instructions for a new antihypertensive medication. Which statement by the client indicates a need for further teaching?

• A. I will stop taking the medication if I experience dizziness.
• B. I will monitor my blood pressure regularly.
• C. I will avoid drinking alcohol while taking this medication.
• D. I will rise slowly from a sitting to a standing position.

Correct answer: A

Rationale: The correct answer is A. Stopping antihypertensive medication abruptly can lead to rebound hypertension, which can be dangerous. Clients should never discontinue their medication without consulting their healthcare provider first. Choice B is correct because monitoring blood pressure is essential when taking antihypertensive medication to ensure it stays within the target range. Choice C is correct as alcohol can potentiate the hypotensive effects of antihypertensive medications. Choice D is correct as orthostatic hypotension can occur, so rising slowly helps prevent dizziness and falls. Therefore, choice A is the statement that indicates a need for further teaching.

3. A healthcare provider is providing discharge teaching to a client who does not speak the same language. Which of the following actions should the healthcare provider take?

• A. Use proper medical terms when providing instructions to the client.
• B. Offer written instructions in the client’s language.
• C. Direct verbal discharge instructions to the interpreter.
• D. Request that an assistive personnel interpret instructions for the client.

Correct answer: B

Rationale: The correct action for the healthcare provider when providing discharge teaching to a client who does not speak the same language is to offer written instructions in the client’s language. This approach helps ensure better comprehension and adherence to the instructions as the client can refer back to the written material for clarification. Choice A is incorrect because using proper medical terms may not be effective if the client does not understand the language. Choice C is incorrect since verbal instructions should be directed to the client for better understanding. Choice D is incorrect as assistive personnel may not be qualified or trained to provide accurate interpretation, risking miscommunication and potential errors in the instructions.

4. While being educated by a nurse, an assistive personnel (AP) is learning about proper hand hygiene. Which statement made by the AP indicates a good understanding of the teaching?

• A. There are times I should use soap and water rather than alcohol-based hand rub to clean my hands.
• B. I can use alcohol-based hand rub after using the restroom.
• C. Soap and water are only necessary if my hands are visibly dirty.
• D. Hand rub is always sufficient, regardless of the situation.

Correct answer: C

Rationale: Choice C is the correct answer because it demonstrates an understanding that soap and water should be used when hands are visibly dirty or when dealing with specific pathogens. Choice A is incorrect because it suggests the use of soap and water over alcohol-based hand rub without specifying the circumstances. Choice B is incorrect as it implies that using alcohol-based hand rub after using the restroom is always suitable. Choice D is incorrect because it states that hand rub is always enough, which is not true when hands are visibly soiled or when specific pathogens are present.

5. The client is learning about lifestyle changes to manage hypertension. Which statement by the client requires further teaching?

• A. I will reduce my salt intake.
• B. I will exercise for 30 minutes most days of the week.
• C. I will drink alcohol only on the weekends.
• D. I will monitor my blood pressure regularly.

Correct answer: C

Rationale: The correct answer is C. Clients with hypertension should ideally avoid or limit alcohol intake rather than just restricting it to weekends. Excessive alcohol consumption can raise blood pressure and interfere with the effectiveness of hypertension management. Choices A, B, and D are all positive statements that align with managing hypertension: reducing salt intake, regular exercise, and monitoring blood pressure are all beneficial lifestyle changes for individuals with hypertension. Therefore, the statement about drinking alcohol only on weekends requires further teaching to emphasize the importance of reducing alcohol consumption for better blood pressure control.

Similar Questions