Nokea
The nurse can best ensure the safety of a client suffering from dementia who wanders from the room by which action?
- A. Repeatedly remind the client of the time and location
- B. Explain the risks of walking with no purpose
- C. Use protective devices to keep the client in the bed or chair in the room
- D. Attach a wander-guard sensor band to the client's wrist
Correct Answer: D
Rationale: This type of identification band easily tracks the client's movements and ensures safety while the client wanders on the unit. Restriction of activity is inappropriate for any client unless they are potentially harmful to themselves or others.
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An adult client was admitted for congestive heart failure today. An IV is running. The nurse enters the room and notes that the client is having increased difficulty breathing. Before calling the physician, what action should the nurse take?
- A. Increase the IV drip rate
- B. Place the client in a supine position
- C. Ask the client if this has happened before
- D. Raise the head of the bed
Correct Answer: D
Rationale: Raising the head of the bed improves breathing in congestive heart failure by reducing pulmonary congestion. Increasing IV rate, supine positioning, or questioning delays intervention.
An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client's confusion by:
- A. Assigning a nursing assistant to sit with him until he falls asleep
- B. Allowing the client to room with another elderly client
- C. Administering a bedtime sedative
- D. Leaving a night light on during the evening and night shifts
Correct Answer: D
Rationale: A night light reduces confusion by improving visibility and orientation. Constant supervision is impractical, room-sharing may worsen confusion, and sedatives increase fall risk.
A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement?
- A. Assist maternal pushing efforts by applying fundal pressure during each contraction
- B. Document the time the fetal head was born
- C. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis
- D. Prepare for a forceps-assisted birth
- E. Request additional assistance from other nurses immediately
Correct Answer: C,E
Rationale: Shoulder dystocia requires urgent interventions like the McRoberts maneuver (flexing legs back, C) and suprapubic pressure (C) to dislodge the fetal shoulder. Additional assistance (E) is critical. Fundal pressure (A) can worsen impaction. Documentation (B) is secondary to immediate action. Forceps (D) are not typically used for shoulder dystocia.
The nurse preceptor observes a graduate practical nurse collecting a urine sample for urinalysis and culture as pictured in the exhibit. What is the preceptor's best action?
- A. Advise the graduate nurse to discard the collected urine specimen and record the output
- B. Advise the graduate nurse to use a sterile specimen cup rather than a graduated container for collection
- C. Explain to the graduate nurse that midstream clean catch or straight catheterization is required
- D. Remind the graduate nurse that the specimen should be kept cool until it is sent to the laboratory
Correct Answer: C
Rationale: Urine for culture requires a midstream clean catch or catheterization (C) to avoid contamination. A graduated container (B) is acceptable if sterile. Discarding (A) is unnecessary, and cooling (D) is secondary.
The nurse is assessing a client at 11 weeks gestation. The first day of the client's last menstrual period was September 7. Which of the following findings should the nurse expect to obtain?
- A. reports feeling fetal movement
- B. reports increased urinary frequency
- C. fundal height of 24 cm above the symphysis pubis
- D. estimated delivery date of June 14 using the Naegele rule
- E. fetal heart tones detectable via Doppler ultrasound device
Correct Answer: B,D,E
Rationale: At 11 weeks, increased urinary frequency (B) is expected due to hormonal changes. The Naegele rule (LMP + 1 year - 3 months + 7 days) gives June 14 (D). Fetal heart tones are detectable by Doppler (E). Fetal movement (A) is felt later (16-20 weeks), and fundal height of 24 cm (C) occurs around 24 weeks.