Nokea
A client has soft wrist restraints to prevent her from pulling out her nasogastric tube. Which of the following nursing interventions should be implemented while the restraints are on the client?
- A. Instruct the client not to move while the restraints are in place
- B. Remove the restraints every 4 hours to provide skin care
- C. Secure the restraints to side rails of the bed
- D. Check on the client every 30 minutes while the restraints are on
Correct Answer: D
Rationale: Checking the client every 30 minutes ensures safety, circulation, and skin integrity while restraints are in use. Restraints should be removed every 2 hours for care, not 4, and securing to side rails is unsafe.
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A young adult has been bitten by a human and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. The nurse should prepare the client to receive:
- A. An injection of tetanus toxoid.
- B. An application of a corticosteroid cream.
- C. Closure of the wound with sutures.
- D. Testing for tuberculosis.
Correct Answer: A
Rationale: A human bite with broken skin and a tetanus shot over 5 years ago warrants tetanus toxoid to prevent tetanus infection. The other options are not indicated for this scenario.
A client with a history of rheumatoid arthritis is prescribed prednisone. The nurse should monitor the client for which of the following adverse effects? Select all that apply.
- A. Hyperglycemia.
- B. Osteoporosis.
- C. Weight gain.
- D. Hypertension.
- E. Hypokalemia.
Correct Answer: A, B, C, D, E
Rationale: Prednisone can cause hyperglycemia, osteoporosis, weight gain, hypertension, and hypokalemia.
Which statement about referrals is accurate?
- A. Referrals complement the healthcare teams' abilities to provide optimal care to the client.
- B. Referrals simply allow the client to be discharged into the community with the additional care they need.
- C. Nurses facilitate referrals to only the resources within the facility.
Correct Answer: A
Rationale: Referrals enhance the healthcare team's ability to provide comprehensive care by connecting clients to specialized services, not limited to discharge or internal resources .
A client has atrial fibrillation. The nurse should monitor the client for:
- A. Cardiac arrest
- B. Cerebrovascular accident
- C. Heart block
- D. Ventricular fibrillation
Correct Answer: B
Rationale: Atrial fibrillation increases the risk of thromboembolism, leading to cerebrovascular accident (stroke). Cardiac arrest, heart block, and ventricular fibrillation are less directly associated.
A client with the diagnosis of Bell's palsy is distressed about the change in facial appearance. Which characteristic of Bell's palsy should the nurse tell the client about to help the client cope with the disorder?
- A. It usually resolves when treated with vasodilator medications.
- B. It is similar to stroke, but all symptoms will go away eventually.
- C. It is not caused by stroke, and many clients recover in 3 to 5 weeks.
- D. It is not caused by a tumor, and many clients recover in 3 to 5 weeks.
Correct Answer: C
Rationale: Clients with Bell's palsy should be reassured that they have not experienced a stroke and that symptoms often disappear spontaneously in approximately 3 to 5 weeks. The client is given supportive treatment for symptoms; the treatment does not involve administering vasodilators. Bell's palsy is not usually caused by a tumor. While option D is factually correct, option C directly addresses the client's distress by clarifying the distinction from a stroke, which is a common concern due to facial paralysis, making it the most appropriate response for coping.