Nokea
The nurse should perform which intervention when a client is restrained?
- A. Remove the restraints and provide skin care hourly.
- B. Document the condition of the client's skin every 3 hours.
- C. Assess the restraint every 30 minutes.
- D. Tie the restraint to the side rails.
Correct Answer: C
Rationale: The minimum standard is to visually assess the restraint every 30 minutes. Documentation is typically performed per a checklist or flow sheet. The ends of the restraint are tied to a part of the bed that allows for position changes without unfastening them.
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When a drug is listed as Category X and prescribed to women of child-bearing age/capacity, the nurse and the interdisciplinary team should counsel the client that:
- A. Pregnancy tests might be unreliable while taking the drug.
- B. She must use a reliable form of birth control.
- C. She should not take the Category X drug on days she has intercourse.
- D. She must follow up with an endocrinologist.
Correct Answer: B
Rationale: Category X drugs have many practice limitations when prescribed and dispensed to women. For example, the prescription is valid for only seven days, and if not filled, it expires. The FDA provides a pregnancy-prevention program for clients taking Isotretinoin (Accutane). Prior to prescribing a Category X drug, a pregnancy test should be performed.
The client with DM is receiving care in the home for a foot ulcer. The home health nurse documents the narrative note illustrated. Which problem should be the nurse's priority on the return visit?
- A. Impaired skin integrity related to left foot ulcer
- B. Potential for injury related to improper footwear
- C. Potential altered nutrition: less than body requirements related to nausea
- D. Ineffective therapeutic regimen management related to not taking medications as prescribed
Correct Answer: B
Rationale: Improper footwear increases the risk of injury or falls, which is critical for a diabetic client with reduced foot sensation and a healing ulcer.
After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond by saying
- A. He has a lot of problems. You need to have patience with him.
- B. I will talk with him and try to figure out what to do.
- C. He may be scared and taking it out on you. Let's talk to figure out what to do.
- D. Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day.
Correct Answer: C
Rationale: This response explains the client's behavior without belittling the UAP's feelings. The UAP is encouraged to contribute to the plan of care to help solve the problem.
The nurse is performing a physical examination of a 3 month-old with a suspected heart murmur. Which assessment should be performed first?
- A. Inspect the chest
- B. Auscultate the mass
- C. Percuss the mass
- D. Palpate the mass
Correct Answer: B
Rationale: Auscultate the mass. Auscultation of the chest to listen for a heart murmur is the first step in confirming the presence of a murmur and guides further assessment.
The hospitalized client tells the nurse about feeling a strong shock when turning on an electric hair dryer. What should the nurse do first?
- A. Assess the client's heart rhythm and apical pulse
- B. Disconnect the hair dryer from the electrical outlet
- C. Assess the client's skin for signs of electrical burn
- D. Tag and send the hair dryer for inspection
Correct Answer: A
Rationale: Assessing the client's heart rhythm is the priority, as an electrical shock can cause dysrhythmias due to the body's conductivity.