Nokea
A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?
- A. Remove the restraints from the client's wrists
- B. Review the chart for nonrestraint alternatives for agitation
- C. Speak with the AP about the incident
- D. Inform the unit manager of the incident
Correct Answer: A
Rationale: The correct action for the nurse to take first is to remove the restraints from the client's wrists. Restraints should not be applied without a prescription due to the risk of harm to the client. Removing the restraints promptly is a priority to ensure the client's safety. Reviewing nonrestraint alternatives, speaking with the AP, and informing the unit manager can follow after ensuring the client's immediate safety by removing the restraints.
You may also like to solve these questions
Your patient has been diagnosed with orchiditis. What information about this disorder should you inform the patient about?
- A. This disorder often occurs as a result of streptococcus.
- B. This disorder can be symptomatically treated with ice.
- C. This disorder can be symptomatically treated with heat.
- D. This disorder is typically treated with surgery.
Correct Answer: B
Rationale: Orchiditis can be symptomatically treated with ice to reduce inflammation. Choice A is incorrect because orchiditis is not typically caused by streptococcus. Choice C is incorrect as heat is not the recommended treatment for orchiditis. Choice D is also incorrect as surgery is not the first-line treatment for orchiditis.
Which anatomic malformations are associated with Tetralogy of Fallot?
- A. A sub-aortic septal defect, an overriding aorta, left ventricular hypertrophy, and right ventricular outflow
- B. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and left ventricular outflow
- C. A sub-aortic septal defect, an overriding aorta, pulmonary atresia, and right ventricular outflow
- D. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow
Correct Answer: D
Rationale: Tetralogy of Fallot is characterized by a combination of four heart defects: a sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow obstruction. This leads to mixing of oxygen-poor and oxygen-rich blood, resulting in cyanosis. Therefore, the correct answer is D. Choices A, B, and C are incorrect because they do not accurately describe the specific combination of anatomic malformations seen in Tetralogy of Fallot.
Which of the following is a benefit of the U.S. health-care system?
- A. With cost savings from technology, more Americans now have health-care insurance.
- B. Quality of care has improved in the United States.
- C. Care in the United States has shifted to a prevention focus rather than an illness focus.
- D. The use of technology is projected to decrease health-care costs and improve clinical outcomes.
Correct Answer: D
Rationale: The correct answer is D because the use of technology and electronic health records is projected to decrease health-care costs and improve clinical outcomes, quality, and safety. Choice A is incorrect because it states that very few Americans have no health-care insurance, which is not a benefit of the U.S. health-care system. Choice B may be true, but it does not directly address a benefit of the health-care system. Choice C is not necessarily a benefit but rather a shift in focus, so it is also incorrect.
A nurse is receiving a verbal prescription from the provider for a client who is experiencing increased pain. The nurse should transcribe which of the following prescriptions in the client's medical record?
- A. Morphine sulfate 10 mg IV q 4 IV prn for pain
- B. MS 10 mg IV every 4 8 prn for pain
- C. MSO4 10 mg IVP q 4 8 prn for pain
- D. Morphine sulfate 10.0 mg every 4 hours IV prn for pain
Correct Answer: A
Rationale: The correct transcription is 'Morphine sulfate 10 mg IV q 4 IV prn for pain.' In choice A, 'Morphine sulfate 10 mg IV q 4 IV prn for pain' correctly indicates the medication, route (IV), frequency (every 4 hours), and administration as needed for pain control. Choice B is incorrect as 'MS' is not a standard abbreviation for Morphine Sulfate, and the frequency 'every 4 8' is not a valid time interval. Choice C is incorrect as 'MSO4' is not the standard abbreviation for Morphine Sulfate, and 'IVP' is not the standard route abbreviation for intravenous. Choice D is incorrect as it lacks clarity with '10.0 mg' instead of '10 mg,' and the frequency is given as 'every 4 hours' without specifying the route of administration.
Which of the following new opportunities might a new nurse see in the future?
- A. Transitional care
- B. Traditional care
- C. Hospital-based care
- D. Care based on cost
Correct Answer: A
Rationale: In the future, new nurses may see opportunities in transitional care. Transitional care involves the coordination and continuity of healthcare during a movement from one healthcare setting to another. This type of care is increasingly important in today's healthcare landscape due to the focus on improving patient outcomes and reducing hospital readmissions. Choices B, C, and D are incorrect as they do not represent emerging opportunities for new nurses in the future. Traditional care and hospital-based care are existing models of care delivery, while care based solely on cost does not align with the holistic approach to patient care that is becoming more prevalent in healthcare.