A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?

Offer fruit juice at least twice during both the day and evening shifts.

Encourage the client to eat all of the meals that are sent.

Lower the bed prior to helping the client to move up in bed.

Have the client hold a pillow over the abdomen to cough and deep breathe.

Answer and Explanation

The Correct Answer is D

Choice A reason: Offering fruit juice is part of good nutrition and hydration but does not directly assist with the client's breathing difficulty.

Choice B reason: Encouraging the client to eat all meals is important for nutritional support, but it is not the most critical action related to the client's immediate respiratory comfort.

Choice C reason: Lowering the bed may be a safety measure but does not address the client's need for respiratory support.

Choice D reason: Having the client hold a pillow over the abdomen can help splint the chest while coughing, reducing discomfort and facilitating deep breathing, which is essential for a client with emphysema experiencing difficulty breathing.

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Correct Answer is D

Explanation

The correct answer is choice D. Paper mask and gown.

Choice A rationale:

The stethoscope is not typically placed in a biohazard bag. It is cleaned and disinfected after each use, especially when used with a patient with an infectious disease like MRSA.

Choice B rationale:

Bed linens are usually placed in a designated linen bag, not a biohazard bag, even when the patient has an infectious disease. The linens are then laundered according to the healthcare facility’s infection control guidelines.

Choice C rationale:

A sputum specimen is typically placed in a designated specimen container, not a biohazard bag. The container is then sent to the lab for analysis.

Choice D rationale:

The paper mask and gown used while caring for a patient with MRSA should be placed in a designated biohazard bag before being removed from the room. This is because these items may have come into contact with the bacteria and could potentially spread the infection.

A. Bowel incontinence. B. Impaired bed mobility. C. Fluid volume deficit. D. Caregiver role strain.

Correct Answer is C

Explanation

Choice A reason: While bowel incontinence is a concern, it does not pose an immediate threat to the client's physiological stability like fluid volume deficit does.

Choice B reason: Impaired bed mobility is important to address for long-term rehabilitation, but it is not the most immediate threat to life.

Choice C reason: Fluid volume deficit, especially due to diarrhea, can lead to dehydration and is a life-threatening condition that requires immediate intervention.

Choice D reason: Caregiver role strain is a significant issue but does not take precedence over the client's immediate physical health needs.

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A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?

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A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. When caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

Correct Answer is D

Explanation

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

Correct Answer is C

Explanation

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?

A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?

The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

Exhibits What other recommendations could the nurse give to help the patient have better sleep? Select all that apply.

The nurse is preparing an in-service on the Health Insurance Portability and Accountability Act (HIPAA) violations. Which example should the nurse use to demonstrate a HIPAA violation?

A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?

When interviewing a client about sexuality/reproductive function, which is the best approach for the nurse to use?