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2027 (RATIONALES)
The nurse is assessing several clients prior to surgery. Which factor in a
client's history poses the greatest threat for complications to occur during
surgery?
A. Taking birth control pills for the past 2 years
B. Taking anticoagulants for the past year
C. Recently completing antibiotic therapy
D. Having taken laxatives PRN for the last 6 months
B
Rationale:
Anticoagulants increase the risk for bleeding during surgery, which can pose a
threat for the development of surgical complications. The health care provider
should be informed that the client is taking these drugs. Although clients who
take birth control pills may be more susceptible to the development of
thrombi, such problems usually occur postoperatively. A client with option C or
D is at less of a surgical risk than with option B.
,When assisting a client from the bed to a chair, which procedure is best for the
nurse to follow?
A. Place the chair parallel to the bed, with its back toward the head of the bed
and assist the client in moving to the chair.
B. With the nurse's feet spread apart and knees aligned with the client's
knees, stand and pivot the client into the chair.
C. Assist the client to a standing position by gently lifting upward, underneath
the axillae.
D. Stand beside the client, place the client's arms around the nurse's neck,
and gently move the client to the chair.
B
Rationale: Option B describes the correct positioning of the nurse and affords
the nurse a wide base of support while stabilizing the client's knees when
assisting to a standing position. The chair should be placed at a 45-degree
angle to the bed, with the back of the chair toward the head of the bed.
Clients should never be lifted under the axillae; this could damage nerves
and strain the nurse's back. The client should be instructed to use the arms of
the chair and should never place his or her arms around the nurse's neck; this
places undue stress on the nurse's neck and back and increases the risk for a
fall.
,Which step(s) should the nurse take when administering ear drops to an adult
client? (Select all that apply.)
A. Place the client in a side-lying position.
B. Pull the auricle upward and outward.
C. Hold the dropper 6 cm above the ear canal.
D. Place a cotton ball into the inner canal.
E. Pull the auricle down and back.
A, B
Rationale: The correct answers (A and B) are the appropriate administration of
ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C).
A cotton ball should be placed in the outermost canal (D). The auricle is
pulled down and back for a child younger than 3 years of age, but not an
adult (E).
The nurse is instructing a client in the proper use of a metered-dose inhaler.
Which instruction should the nurse provide the client to ensure the optimal
benefits from the drug?
A. "Fill your lungs with air through your mouth and then compress the inhaler."
B. "Compress the inhaler while slowly breathing in through your mouth."
C. "Compress the inhaler while inhaling quickly through your nose."
D. "Exhale completely after compressing the inhaler and then inhale."
B
Rationale: The medication should be inhaled through the mouth
simultaneously with compression of the inhaler. This will facilitate the
desired destination of the aerosol medication deep in the lungs for an
optimal bronchodilation effect. Options A, C, and D do not allow for deep
lung penetration.
, A 20-year-old female client with a noticeable body odor has refused to
shower for the last 3 days. She states, "I have been told that it is harmful to
bathe during my period." Which action should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation with the client.
D
Rationale: Because a shower is most beneficial for the client in terms of
hygiene, the client should receive teaching first, respecting any personal
beliefs such as cultural or spiritual values. After client teaching, the client
may still choose option A or B. Brochures reinforce the teaching.
While reviewing the side effects of a newly prescribed medication, a 72-
year-old client notes that one of the side effects is a reduction in sexual
drive. Which is the best response by the nurse?
A. "How will this affect your present sexual activity?"
B. "How active is your current sex life?"
C. "How has your sex life changed as you have become older?"
D. "Tell me about your sexual needs as an older adult."
A
Rationale: Option A offers an open-ended question most relevant to the
client's statement. Option B does not offer the client the opportunity to
express concerns. Options C and D are even less relevant to the client's
statement.