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A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using restraints, which of the following actions must the nurse take first?
- A. Obtain a prescription for restraints from the provider.
- B. Explain the procedure to the client and their family.
- C. Attempt less restrictive alternatives.
- D. Document the indications for using wrist restraints.
Correct Answer: C
Rationale: Correct Answer: C - Attempt less restrictive alternatives.
Rationale: Before resorting to using restraints, the nurse must first try less restrictive measures to ensure the safety and well-being of the client. This includes interventions such as redirecting the client's behavior, providing distractions, or addressing the underlying cause of the behavior. By attempting less restrictive alternatives, the nurse can promote the client's autonomy and prevent the potential negative effects of using restraints.
Summary:
A: Obtaining a prescription for restraints is important, but it should not be the first step.
B: Explaining the procedure to the client and their family is important but does not address the immediate need for less restrictive alternatives.
D: Documenting the indications for using wrist restraints is necessary but does not address the need to explore other options first.
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A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
- A. The client drinks their thickened juice with a straw.
- B. The client adjusts the head of their bed to 90°.
- C. The client tucks their chin when they swallow.
- D. The client takes frequent breaks while eating.
Correct Answer: A
Rationale: Correct Answer: A. The client drinking thickened juice with a straw indicates a potential aspiration risk. Straws can bypass the oral phase of swallowing, increasing the likelihood of aspiration. Thickened liquids are meant to slow down the flow of fluids to prevent choking or aspiration. Therefore, the nurse should intervene to prevent potential harm to the client.
Incorrect Choices:
B: Adjusting the head of the bed to 90° is the correct positioning to prevent aspiration during swallowing.
C: Tucking the chin when swallowing helps to protect the airway and prevent aspiration.
D: Taking frequent breaks while eating is a good strategy for clients with dysphagia to prevent fatigue and reduce the risk of aspiration.
A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include?
- A. Change the dressing four times per day.
- B. Apply tincture of benzoin prior to removing the dressing.
- C. Use sterile gloves when removing the old dressing.
- D. Clean from the incision to the surrounding skin.
Correct Answer: C
Rationale: The correct answer is C: Use sterile gloves when removing the old dressing. This is important to prevent introducing infection to the incision site. Sterile gloves help maintain asepsis during the dressing change, reducing the risk of contamination. Changing the dressing four times per day (A) may disrupt the wound healing process by removing necessary protective barriers. Applying tincture of benzoin (B) can cause skin irritation and is unnecessary for routine dressing changes. Cleaning from the incision to the surrounding skin (D) can introduce microorganisms from the surrounding skin to the incision site, increasing infection risk.
A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?
- A. The client takes an antihypertensive medication.
- B. The client has electrical wires secured to baseboards.
- C. The client wears rubber-sole shoes.
- D. The client's visual acuity is 20/40.
Correct Answer: A
Rationale: The correct answer is A because taking antihypertensive medication can lead to orthostatic hypotension, increasing fall risk. Choice B is incorrect as securing electrical wires actually reduces tripping hazards. Choice C is incorrect as rubber-sole shoes provide better traction. Choice D is incorrect as 20/40 visual acuity alone may not directly contribute to fall risk.
A nurse is preparing to administer prescribed medications to a client. According to the rights of medication administration, when should the nurse compare the medication administration record against the medication container? (Select all that apply.)
- A. While removing medication from the container
- B. Before selecting the medication container
- C. When documenting the medication administration
- D. When providing client education about the medication
- E. At the client's bedside before administering the medication
Correct Answer: A, B,E
Rationale: The correct answers are A, B, and E. Comparing the medication administration record against the container before removing the medication ensures accuracy. Before selecting the container, the nurse confirms the correct medication. At the client's bedside, the nurse verifies the medication before administration to prevent errors. Choice C is incorrect because documentation should occur after administration. Choice D is incorrect as medication reconciliation is not part of client education.
A nurse is caring for a client who has a traumatic brain injury and needs to relearn how to use eating utensils. The nurse should refer the client to which of the following members of the interprofessional team?
- A. Physical therapist
- B. Speech-language pathologist
- C. Occupational therapist
- D. Social worker
Correct Answer: C
Rationale: The correct answer is C: Occupational therapist. Occupational therapists specialize in helping individuals regain skills needed for daily activities, such as using eating utensils. They focus on enhancing fine motor skills and cognitive abilities necessary for independent living. Referring the client to an occupational therapist will ensure a comprehensive approach to relearning utensil use. Physical therapists (A) focus on mobility and strength, not fine motor skills. Speech-language pathologists (B) address communication and swallowing issues, not utensil use. Social workers (D) assist with psychosocial support, not utensil retraining.