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A nurse is working with a client in an extended care facility. Which bed position is preferred for a client, who is at risk for falls, as part of a prevention protocol?
- A. All 4 side rails up, wheels locked, bed closest to door
- B. Lower side rails up, bed facing doorway
- C. Knee-high, head slightly elevated, bed in lowest position
- D. Bed in lowest position, wheels locked, place bed against wall
Correct Answer: D
Rationale: Bed in lowest position, wheels locked, place bed against wall. Using all 4 side rails is considered a restraint and limits client autonomy unless medically necessary with an order. Lower side rails alone do not adequately prevent falls. The bed in the lowest position with wheels locked and placed against the wall minimizes fall risk while allowing the client freedom of movement.
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A client with pneumococcal pneumonia was started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul taste and smell to the client's sputum. Which one would alert the nurse to a complication?
- A. I have a sharp pain in my chest when I take a breath.'
- B. I have been coughing up foul-tasting, brown, thick sputum.'
- C. I have been sweating all day.'
- D. I feel hot off and on.'
Correct Answer: B
Rationale: Foul smelling and tasting sputum signals a risk of a lung abscess. This puts the client in grave danger since abscesses are often caused by anaerobic organisms. This client most likely would need a change of antibiotics. Sharp chest pain on inspiration called pleuritic pain is an expected finding with this type of pneumonia. The other options are expected in the initial 24 to 48 hours of therapy for infections.
The client who has airborne precautions asks the nurse not to shut his door. Which response by the nurse is most appropriate?
- A. "If I open the door you will need to always wear a mask."
- B. "The door must be kept closed, but I can open the curtains."
- C. "Don't worry; I can leave the door open if it's bothering you."
- D. "I'm sorry, but I can only leave the door partially open."
Correct Answer: B
Rationale: B: Keeping the door closed contains airborne pathogens; opening curtains reduces isolation feelings. A, C, D: Open or partially open doors risk pathogen spread.
The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching?
- A. I use a sliding scale to adjust regular insulin to my sugar level.'
- B. Since my eyesight is so bad, I ask the nurse to fill several syringes.'
- C. I keep my regular insulin bottle in the refrigerator.'
- D. I always make sure to shake the NPH bottle hard to mix it well.'
Correct Answer: D
Rationale: I always make sure to shake the NPH bottle hard to mix it well.' The bottle should be rolled gently, not shaken.
The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the provider?
- A. nausea and vomiting
- B. fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
- C. diffuse macular rash
- D. muscle tenderness
Correct Answer: B
Rationale: fever of 103 degrees Fahrenheit (39.5 degrees Celsius). Persistent, prolonged fever may be an indication that the antibiotics are not effective and may need to be changed.
An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?
- A. Stay with client and observe for airway obstruction
- B. Collect pillows and pad the side rails of the bed
- C. Place an oral airway and use the body
- D. Announce a cardiac arrest, and assist with intubation
Correct Answer: A
Rationale: Stay with client and observe for airway obstruction. For the client's safety, remain at the bedside and observe respirations and level of consciousness. Prepare to clear the airway if obstructed. Do not place anything in the client's mouth. For safety, do not leave the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the seizure.