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 C

Explanation

A radial pulse is the pulse felt at the wrist, where the radial artery runs along the thumb side of the forearm. It is one of the most common sites for measuring a person's heart rate⁴.

To measure a radial pulse, the examiner should place two or three fingers over the radial artery, just below the wrist crease, and apply gentle pressure until a pulsation is felt. The examiner should not use the thumb, as it has its own pulse and may interfere with the accuracy of the measurement. The examiner should count the number of beats for 15, 30, or 60 seconds, depending on the regularity and rate of the pulse³⁵.

In the picture, the unlicensed assistive personnel (UAP) is using the thumb to measure the radial pulse, which is incorrect. The practical nurse (PN) should demonstrate the correct pulse site to the UAP and explain why using the thumb is not appropriate. This will help to ensure that the UAP obtains an accurate and reliable pulse rate for the client.

A. Check the functioning of oxygen equipment once each week. B. Wear clothing made with cotton fabrics while oxygen is in use. C. Apply petroleum-based lubricant to the nares as needed. D. Store full oxygen tanks on their side.

Correct Answer is B

Explanation

A. Incorrect. The nurse should check the functioning of oxygen equipment daily, not weekly, to ensure safety and proper delivery of oxygen.

B. Correct. The nurse should instruct the client to wear clothing made with cotton fabrics while oxygen is in use, as synthetic fabrics can generate static electricity and cause sparks that could ignite the oxygen.

C. Incorrect. The nurse should instruct the client to avoid petroleum-based lubricants, such as Vaseline, as they are flammable and could cause burns if exposed to oxygen. The nurse should recommend water-soluble lubricants, such as K-Y jelly, instead.

D. Incorrect. The nurse should instruct the client to store full oxygen tanks upright, not on their side, to prevent them from rolling and damaging the valve or regulator.

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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

The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PN take?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

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