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A client has received electroconvulsive therapy (ECT). What intervention should the nurse perform first in the posttreatment area and upon the client's awakening?
- A. Assist the client from the stretcher to a wheelchair.
- B. Orient the client and monitor his or her vital signs.
- C. Offer the client frequent reassurance and repeat orientation statements.
- D. Assess for a gag reflex so that the client can eat and drink with safety.
Correct Answer: B
Rationale: The nurse should first monitor vital signs, orient the client, and review with the client that he or she just received an ECT treatment. The posttreatment area should include accessibility to the anesthesia staff, oxygen, suction, pulse oximeter, vital sign monitoring, and emergency equipment. The nursing interventions outlined in the remaining options will follow accordingly.
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A client has started taking amiodarone (Cordarone). The nurse should inform the client that periodic laboratory tests will be done to monitor the client's:
- A. Hemoglobin.
- B. Liver enzymes.
- C. Creatine kinase (CK) concentration.
- D. Renal function.
Correct Answer: B
Rationale: Amiodarone can cause hepatotoxicity, so periodic monitoring of liver enzymes is necessary to detect potential liver damage.
The nurse is assessing the leg pain of a client who has just undergone right femoral-popliteal artery bypass grafting. Which question would be most useful in determining whether the client is experiencing graft occlusion?
- A. Can you describe what the pain feels like?
- B. Can you rate the pain on a scale of 1 to 10 ?
- C. Did you get any relief from the last dose of pain medication?
- D. Can you compare this pain to the pain you felt before surgery?
Correct Answer: D
Rationale: The most frequent indication that a graft is occluding is the return of pain that is similar to that experienced preoperatively. Standard pain assessment techniques also include the items described in the remaining options, but these will not help differentiate current pain from preoperative pain.
You have loosely applied a bed sheet around your client's waist to prevent a fall from the chair. What have you done?
- A. Ensured the client's safety which is a high patient care priority
- B. Violated Respondeat Superior
- C. Violated the client's right to dignity
- D. Committed a crime
Correct Answer: D
Rationale: Applying a bed sheet around the client's waist without a proper restraint order constitutes an illegal restraint, which is a crime , as it restricts freedom without proper authorization or consent.
A client is reporting skin irritation from the edges of a cast that was applied the previous day. The nurse notes that the skin is pink and irritated. Which corrective action should the nurse take?
- A. Petal the edges of the cast with tape.
- B. Massage the skin at the rim of the cast.
- C. Shake a small amount of powder under the cast rim.
- D. Use a hair dryer set on a cool high setting to soothe the irritation.
Correct Answer: A
Rationale: The nurse should petal the edges of the cast with tape to minimize skin irritation. Massaging the skin will not help the problem. Powder should not be shaken under the cast because it could clump, become moist, and cause skin breakdown. A hair dryer is used on a cool low setting if a nonplaster cast becomes wet or if the client's skin itches under a cast.
Which statement about environmental safety is accurate?
- A. The nurse should advise clients in a smoke filled room to open the windows.
- B. The first thing that the nurse should do when using a fire extinguisher to put out a small fire is to aim the fire extinguisher at the base of the fire.
- C. Rapidly lift and move a client away from the source of the fire when their slippers are on fire.
- D. The home health care nurse should advise the client that the best fire extinguisher to have in the home is an ABC fire extinguisher.
Correct Answer: D
Rationale: Advising clients to have an ABC fire extinguisher is accurate, as it is versatile for multiple fire types. Opening windows may worsen a fire, aiming the extinguisher follows pulling the pin, and rapid lifting risks injury.