A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship?

Determine previous coping skills used by the client.

Facilitate the client's problem-solving skillls

Assist the client in expressing alternative behaviours.

Establish the responsibilities of the nurse and client

Answer and Explanation

The Correct Answer is D

Choice A reason:
Determine previous coping skills used by the client is not appropriate. Assessing the client's previous coping skills is an essential step in the assessment phase of the therapeutic relationship, not specifically during the orientation phase. This information helps the nurse to understand the client's coping mechanisms and identify potential areas for improvement or support.
Choice B reason:
Facilitate the client's problem-solving skills is not appropriate the nurse may work on facilitating the client's problem-solving skills throughout the therapeutic relationship, including during the working phase. During this phase, the nurse and client collaborate to explore and address the client's concerns and challenges.
Choice C reason:
Assisting the client in expressing alternative behaviours is not appropriate. This action may also be part of the working phase, where the nurse helps the client explore alternative behaviours and coping strategies to address their issues and challenges.
Choice D reason:
The orientation phase is the initial stage of the therapeutic relationship where the nurse and the client get to know each other and establish the groundwork for their working relationship. During this phase, it is essential to clarify the roles and responsibilities of both the nurse and the client to ensure a clear understanding of each other's expectations.

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Correct Answer is D

Explanation

A. Hold hands folded below the waist after donning sterile gloves. This is incorrect because holding hands below the waist can contaminate the gloves with microorganisms from the floor or clothing.

B. Pick up and pour solutions with the palm of the hand covering bottle labels. This is incorrect because covering bottle labels can obscure important information such as expiration dates or ingredients.

C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. This is incorrect because the border of the sterile drape is considered contaminated and any sterile item that touches it becomes contaminated as well.

D. Maintain sterile objects within the line of vision. This is correct because keeping an eye on sterile objects ensures that they are not accidentally touched by nonsterile items or persons.

A. Thinning of mucous secretions B. Decreased peak inspiratory pressure C. Presence of a productive cough D. Flattening of the artificial airway cuff

Correct Answer is B

Explanation

Choice A reason

While thinning of secretions can be a positive sign, it's not always visible. A decrease in peak inspiratory pressure is a more objective indicator of improved airway patency.

Choice B reason.

Peak inspiratory pressure is the maximum pressure required to push air into the lungs. If suctioning is effective, it will remove secretions and reduce airway resistance, leading to a decrease in peak inspiratory pressure.

Choice C reason:

While a productive cough can indicate that secretions are being moved, it doesn't directly measure the effectiveness of suctioning.

Choice D reason:

Flattening of the artificial airway cuff: Flattening of the artificial airway cuff is not a relevant indicator of the effectiveness of suctioning. The cuff of an endotracheal tube is inflated to prevent air leaks around the tube and to maintain proper ventilation. It is not directly related to the effectiveness of suctioning.

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A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?

Correct Answer is D

Explanation

A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?

Correct Answer is B

Explanation

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