A nurse is caring for a client who has coronary artery disease and has a BMI of 30. Which of the following strategies should the nurse implement first to develop teaching that promotes lifestyle changes?

Determine what the client knows about coronary artery disease.

Identify resources that will help support the client's lifestyle changes.

Establish mutual learning goals with the client.

Schedule a teaching session about coronary artery disease in a quiet setting.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Determining what the client knows about coronary artery disease is an important step in assessing the client's baseline knowledge. However, it's not the first step in developing teaching strategies. First, the nurse should establish a collaborative relationship with the client to set mutual learning goals.

Choice B rationale:

Identifying resources that will help support the client's lifestyle changes is an essential aspect of the teaching process, but it's not the initial step. The nurse needs to work with the client to set goals and develop a plan before seeking external resources.

Choice C rationale:

Establishing mutual learning goals with the client is the most crucial first step. This approach ensures that the teaching plan aligns with the client's needs and preferences, fostering a sense of partnership and increasing the likelihood of successful lifestyle changes.

Choice D rationale:

Scheduling a teaching session about coronary artery disease in a quiet setting is an important consideration for effective teaching, but it comes after the nurse and the client have identified mutual learning goals. The nurse should engage the client in goal-setting before planning specific teaching sessions.

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Correct Answer is B

Explanation

Choice A rationale:

Moving the client using a slider board might be appropriate for transferring clients with relatively lower weight and mobility challenges. However, in this scenario, where the client weighs 136 kg (300 lb), a more advanced transfer method is necessary to ensure the safety of both the client and the healthcare providers.

Choice B rationale:

Using an air-assisted transfer device is suitable for transferring clients with higher weight, as it helps reduce friction and strain during the transfer process. This approach ensures a smoother transfer and minimizes the risk of injury to both the client and the assistive personnel.

Choice C rationale:

Raising the bed to 5 cm (2 in) above the level of the stretcher might not provide enough clearance for a safe transfer. Additionally, the use of assistive devices is more appropriate for transferring clients with significant weight, rather than relying solely on adjusting the bed height.

Choice D rationale:

Positioning the head of the bed at 25° prior to the transfer is not directly relevant to the process of transferring a client from a bed to a stretcher. The focus should be on using appropriate equipment and techniques for safe and efficient transfer, especially considering the client's weight.

A. Unclamp the client's gastrostomy tube before connecting the syringe to it. B. Verify that the client's gastric pH is at least 7 prior to feeding. C. Pour the client's formula into the syringe, raising or lowering it to control the rate of flow. D. Apply sterile gloves before accessing the client's gastrostomy tube.

Correct Answer is A

Explanation

Choice A rationale:

Unclamping the client's gastrostomy tube before connecting the syringe is the correct action. This allows the feeding to flow freely into the stomach. Clamping the tube while administering the feeding would prevent the formula from entering the stomach properly.

Choice B rationale:

Verifying the client's gastric pH to be at least 7 prior to feeding is not necessary for administering intermittent enteral feedings. Gastric pH varies widely among individuals and is not a standard requirement before every feeding.

Choice C rationale:

Pouring the client's formula into the syringe and adjusting the syringe's height to control the rate of flow is not recommended. Controlling the rate of flow in this manner is imprecise and can lead to inconsistent delivery of the formula, potentially causing discomfort or complications.

Choice D rationale:

Applying sterile gloves before accessing the client's gastrostomy tube is an important step in infection control, but it is not specifically related to administering intermittent enteral feedings. Sterile gloves are essential to prevent contamination and infection during tube maintenance and insertion, not during the feeding process itself.

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A nurse is caring for a client who has coronary artery disease and has a BMI of 30. Which of the following strategies should the nurse implement first to develop teaching that promotes lifestyle changes?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to transfer a client who weighs 136 kg (300 lb) from a bed to a stretcher with the aid of an assistive personnel (AP). Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving intermittent enteral feedings via a gastrostomy tube. Which of the following actions should the nurse take when administering the feeding?

Correct Answer is A

Explanation

A nurse is performing a focused assessment of a client's sensory functions. Which of the following tests should the nurse perform?

A nurse is completing a preadmission interview for a client who is to undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the nurse include when planning care for the client's surgery? (Select all that apply)

A nurse is caring for a client who has a temperature of 40°C (104°F). Which of the following interventions should the nurse take?

A nurse is admitting a client who has rubella. Which of the following actions should the nurse plan to take?

A nurse is planning care for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse include to reduce the client's risk for ventilator-associated pneumonia?

A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?

A nurse is reviewing transmission precautions with an assistive personnel (AP) who is providing care for a client who has a Clostridium difficile infection. Which of the following statements by the AP indicates an understanding of the teaching?

A nurse is reviewing the client's right to refuse treatment with other members of the health care team. The nurse should identify this right as which of the following ethical principles?