Nokea
A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following?
- A. Administer PRN haloperidol (Haldol) to decrease the need to walk
- B. Assess the client's gait for steadiness
- C. Restrain the client in a geriatric chair
- D. Administer PRN lorazepam (Ativan) to provide sedation
Correct Answer: B
Rationale: Assessing the client's gait for steadiness is the most appropriate action to ensure the safety of a client with dementia while walking. This allows the nurse to identify any issues that may increase the risk of falls or accidents. Administering PRN haloperidol or lorazepam is not indicated as the first-line approach in managing wandering behavior and can have adverse effects like increased risk of falls, confusion, or oversedation. Restraint use should be avoided whenever possible, as it can lead to physical and psychological harm to the client.
You may also like to solve these questions
What should a healthcare professional do when they observe signs of phlebitis in a client receiving IV fluids?
- A. Apply a cold compress
- B. Notify the physician immediately
- C. Apply a warm compress
- D. Administer anti-inflammatory medication
Correct Answer: C
Rationale: When signs of phlebitis are observed in a client receiving IV fluids, the appropriate action is to apply a warm compress. This helps to reduce discomfort and swelling at the site of the IV insertion. Applying a cold compress may not be as effective in this case and could potentially worsen the condition. While notifying the physician is important, providing immediate comfort to the client through a warm compress is the initial recommended intervention. Administering anti-inflammatory medication should only be done under the direction of a healthcare provider after assessment and evaluation of the client's condition.
A healthcare professional is preparing to transfer a client who has had a stroke and is at risk for falling to a rehabilitation facility. Which of the following information should the healthcare professional include in the transfer report?
- A. The client's urination habits.
- B. The client's financial information.
- C. The client's social history.
- D. The client's current level of mobility.
Correct Answer: D
Rationale: The client's current level of mobility is essential to be included in the transfer report for the rehabilitation facility to develop an appropriate care plan. Understanding the client's mobility status helps in determining the level of assistance and interventions needed to prevent falls and promote safe rehabilitation. Choices A, B, and C are not directly related to the client's immediate care needs during the transfer to the rehabilitation facility, making them less relevant for the transfer report.
A nurse is caring for a client who is at 41 weeks of gestation and is receiving oxytocin for labor induction. The nurse notes early decelerations on the fetal heart rate monitor. Which of the following nursing actions should the nurse take?
- A. Continue to monitor the fetal heart rate.
- B. Stop the oxytocin infusion.
- C. Perform a vaginal examination.
- D. Initiate an amnioinfusion.
Correct Answer: A
Rationale: The correct action for early decelerations, which are caused by fetal head compression and are considered normal during labor, is to continue monitoring the fetal heart rate. Early decelerations mirror contractions and usually do not require any intervention. Stopping the oxytocin infusion (Choice B) is not necessary as early decelerations are not typically a cause for concern related to oxytocin. Performing a vaginal examination (Choice C) or initiating an amnioinfusion (Choice D) are unnecessary and not indicated specifically for early decelerations.
A client is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent dislocation of the prosthesis?
- A. Encourage the client to bend at the waist
- B. Maintain the client in a high-Fowler's position
- C. Place a pillow between the client's legs
- D. Avoid placing a pillow under the client's knees
Correct Answer: C
Rationale: Placing a pillow between the client's legs is beneficial after hip replacement surgery to maintain proper alignment and prevent dislocation of the prosthesis. This position helps keep the hip in a neutral position, reducing the risk of dislocation. Encouraging the client to bend at the waist (Choice A) can increase the risk of hip dislocation. Maintaining the client in a high-Fowler's position (Choice B) and avoiding placing a pillow under the client's knees (Choice D) do not directly address the need to maintain proper alignment of the hip joint to prevent dislocation.
What is the role of a nurse in managing a patient with kidney disease?
- A. Monitor blood pressure and provide dietary education
- B. Monitor urine output and provide IV fluids
- C. Administer diuretics and restrict fluid intake
- D. Monitor for cardiac arrhythmias and provide dialysis
Correct Answer: A
Rationale: The correct answer is A. Nurses play a crucial role in managing patients with kidney disease by monitoring blood pressure and providing essential dietary education. This helps in maintaining kidney function and overall health. Choice B is incorrect because monitoring urine output and providing IV fluids are tasks usually performed by healthcare providers such as physicians or specialized staff. Choice C is incorrect as administering diuretics and restricting fluid intake are typically prescribed by a physician, and nurses may assist in monitoring the effects. Choice D is incorrect as monitoring for cardiac arrhythmias and providing dialysis are tasks that are usually overseen by healthcare providers with specialized training in cardiology and nephrology.