Nokea
A 78 year-old client with pneumonia has a productive cough, but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration?
- A. Suction the client frequently while restrained
- B. Secure all 4 restraints to 1 side of bed
- C. Obtain a sitter for the client while restrained
- D. Request an order for a cough suppressant
Correct Answer: C
Rationale: Obtain a sitter for the client while restrained. The plan to use safety devices (restraints) should be rethought. Restraints are used to protect the client from harm caused by removing tubes or getting out of bed. In the event that this restricted movement could cause more harm, such as aspiration, then a sitter should be requested. These are to be provided by the facility in the event the family cannot do so. This client needs to cough and be watched rather than restricted. Suctioning will not prevent aspiration in this situation. Cough suppressants should be avoided for this client.
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The nurse administers subcutaneous insulin lispro at 0730 to a client as prescribed and the client consumes breakfast 30 minutes later. At what time is the client at highest risk for experiencing insulin-related hypoglycemia?
- A. 830
- B. 1100
- C. 1330
- D. 1500
Correct Answer: B
Rationale: Insulin lispro peaks 1-2 hours after administration, so 1100 (B), about 3.5 hours post-injection, is the highest risk time for hypoglycemia.
The nurse is reviewing discharge teaching for a client who had surgical repair of a retinal detachment. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply.
- A. Avoid rubbing or scratching the affected eye
- B. Avoid straining when having a bowel movement
- C. Expect occasional flashes of light during recovery
- D. Report any sudden pain to the health care provider
- E. Rest the eyes by refraining from reading and writing
Correct Answer: A, B, D
Rationale: Avoiding rubbing (A), straining (B), and reporting sudden pain (D) prevent complications. Flashes (C) are not expected and require reporting, and eye rest (E) is unnecessary unless specified.
A woman is admitted with Hodgkin's disease. Which does the nurse expect the client to report?
- A. Swollen lymph nodes
- B. A painful rash
- C. Stomach pain
- D. Joint pain
Correct Answer: A
Rationale: Hodgkin's disease typically presents with painless swollen lymph nodes, a hallmark symptom the nurse should expect.
A client with obesity reports several failed attempts at weight loss. Which client statement best indicates that the client is ready and motivated for successful weight loss?
- A. I have signed up to be a dog walker when I normally would watch television.'
- B. I understand that losing weight would improve my health and well-being.'
- C. I want to lose 8 pounds (3.6 kg) so that my formal gown will fit in 4 weeks.'
- D. My spouse and children are always encouraging me to eat healthier.'
Correct Answer: A
Rationale: Signing up as a dog walker (A) shows a concrete behavioral change, indicating readiness. Understanding benefits (B), short-term goals (C), or external encouragement (D) are less indicative of sustained motivation.
A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include to reinforce prior teaching? Select all that apply.
- A. Apply patch to the upper arm or chest
- B. Fold used patches in half with sticky sides together before discarding
- C. Remove patch if dizziness occurs when getting up
- D. Rotate sites each time a new patch is applied
- E. Shave hair before applying patch
Correct Answer: A, B, D
Rationale: Applying to upper arm/chest (A), folding patches (B), and rotating sites (D) ensure safe use. Removing for dizziness (C) requires medical consultation, and shaving (E) can irritate skin.