The nurse is counseling a healthy 30-year-old female client regarding osteoporosis
prevention. Which activity would be most beneficial in achieving the
... [Show More] client's goal of
osteoporosis prevention?
A. Cross-country skiing
B. Scuba diving
C. Horseback riding
D. Kayaking - Correct answer Rationale: A
Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of
the activities listed, cross-country skiing (A) includes the most weight-bearing, whereas
(B, C, and D) involve less.
The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours
after chest tube insertion for hemothorax. What is the best initial action for the nurse to
take?
A. Document this expected decrease in drainage.
B. Clamp the chest tube while assessing for air leaks.
C. Milk the tube to remove any excessive blood clot buildup.
D. Assess for kinks or dependent loops in the tubing. - Correct answer Rationale: D
The least invasive nursing action should be performed first to determine why the
drainage has diminished (D). (A) is completed after assessing for any problems causing
the decrease in drainage. (B) is no longer considered standard protocol because the
increase in pressure may be harmful to the client. (C) is an appropriate nursing action
after the tube has been assessed for kinks or dependent loops.
A practical nurse (PN) tells the charge nurse in a long-term facility that she does not
want to be assigned to one particular resident. She reports that the male client keeps
insisting that she is his daughter and begs her to stay in his room. What is the best
managerial decision?
A. Notify the family that the resident will have to be discharged if his behavior does not
improve.
B. Notify administration of the PN's insubordination and need for counseling about her
statements.
C. Ask the PN what she has done to encourage the resident to believe that she is his
daughter.
D. Reassign the PN until the resident can be assessed more completely for reality
orientation. - Correct answer Rationale: D
Temporary reassignment (D) is the best option until the resident can be examined and
his medications reviewed. He may have worsening cerebral dysfunction from an
infection or electrolyte imbalance. (A) is not the best option because the family cannot
control the resident's actions. The administration may need to know about the situation, [Show Less]