Nokea
A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching?
- A. Placing a belt restraint on a school-age child who has seizures.
- B. Securing wrist restraints to the bed rails for an adolescent.
- C. Applying elbow immobilizers to an infant receiving cleft lip injury.
- D. Keeping the side rails of a toddler's crib elevated.
Correct Answer: D
Rationale: The correct answer is D. Keeping the side rails of a toddler's crib elevated is an appropriate use of restraints to prevent the child from falling, which is an essential safety measure. Placing a belt restraint on a school-age child with seizures (choice A) is not recommended as it can be dangerous during a seizure. Securing wrist restraints to the bed rails for an adolescent (choice B) may cause harm and should not be done routinely. Applying elbow immobilizers to an infant receiving a cleft lip injury (choice C) is not a standard practice for managing this condition and would not be appropriate.
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A nurse is preparing to administer a rectal suppository to a client. What action should the nurse take?
- A. Encourage the client to hold their breath as long as possible.
- B. Insert the suppository just past the anal sphincter.
- C. Lubricate the suppository and insert it 1.5 cm (0.6 in) into the rectum.
- D. Place the client in a Sims' position before inserting the suppository.
Correct Answer: D
Rationale: The correct action the nurse should take when administering a rectal suppository is to place the client in a Sims' position. This position helps facilitate the proper administration of the suppository by allowing better access to the rectum. Encouraging the client to hold their breath as long as possible (Choice A) is unnecessary and not related to the administration of a rectal suppository. Inserting the suppository just past the anal sphincter (Choice B) is incorrect as it may not reach the rectum where it needs to be placed. Lubricating the suppository and inserting it 1.5 cm into the rectum (Choice C) is incorrect as the suppository needs to be inserted deeper into the rectum for proper absorption.
During a change-of-shift report, a nurse is receiving information about an adult female client who is postoperative. Which of the following client information should the nurse report?
- A. The client's oxygen saturation is 95%
- B. The client's blood pressure is 110/70 mm Hg
- C. The client has a temperature of 36.8°C (98.2°F)
- D. The client's heart rate is 88/min
Correct Answer: B
Rationale: The correct answer is B because a blood pressure of 110/70 mm Hg is within the normal range and stable. Reporting this information is crucial to monitor the client's condition postoperatively. Oxygen saturation of 95% is acceptable, a temperature of 36.8°C (98.2°F) is normal, and a heart rate of 88/min is within the expected range for an adult female client, so these values do not raise concerns that require immediate reporting.
A nurse is caring for a client who has osteoarthritis. Which of the following actions should the nurse take?
- A. Apply heat to inflamed joints
- B. Provide passive range-of-motion exercises
- C. Encourage prolonged use of NSAIDs
- D. Apply cold packs to the joints
Correct Answer: A
Rationale: Corrected Rationale: Applying heat to inflamed joints can help relieve pain in clients with osteoarthritis. Heat therapy can help improve blood circulation, relax muscles, and reduce stiffness. Choice B, providing passive range-of-motion exercises, may be beneficial for joint mobility but is not the first-line intervention for pain relief in osteoarthritis. Choice C, encouraging prolonged use of NSAIDs, should be done cautiously due to potential side effects and should be guided by a healthcare provider. Choice D, applying cold packs to the joints, is not recommended for osteoarthritis as cold therapy can worsen stiffness and discomfort in this condition.
A client is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?
- A. Measure the client's blood glucose level every 6 hours
- B. Change the TPN tubing every 24 hours
- C. Weigh the client weekly
- D. Administer the TPN through a peripheral IV line
Correct Answer: B
Rationale: The correct action for the nurse to take when caring for a client receiving total parenteral nutrition (TPN) is to change the TPN tubing every 24 hours. This practice helps reduce the risk of infection in clients receiving parenteral nutrition. Measuring the client's blood glucose level every 6 hours is important for clients on insulin therapy or with diabetes, but it is not directly related to TPN administration. Weighing the client weekly is essential for monitoring fluid status and nutritional progress, but it is not specific to TPN care. Administering TPN through a peripheral IV line is incorrect because TPN solutions are hypertonic and can cause phlebitis or thrombosis if administered through a peripheral line; a central venous access is typically used for TPN administration.
A nurse is preparing to administer a controlled substance. Which of the following actions should the nurse take?
- A. Witness the waste of the controlled substance by another nurse
- B. Dispose of the controlled substance by yourself
- C. Leave the controlled substance in the client's room for later use
- D. Document the administration and sign off at the end of the shift
Correct Answer: A
Rationale: The correct action for the nurse preparing to administer a controlled substance is to witness the waste of the controlled substance by another nurse. This practice is crucial to prevent misuse and ensure accurate documentation. Choice B is incorrect because disposing of the controlled substance by oneself without proper witnessing is not in accordance with safety protocols. Choice C is incorrect as leaving a controlled substance unattended in a client's room poses risks of diversion or unauthorized access. Choice D is incorrect because documenting the administration and signing off at the end of the shift is important but does not specifically address the issue of witnessing the waste of a controlled substance, which is a critical step in ensuring proper handling and accountability.