Nokea
A client was admitted to the psychiatric unit after refusing to get out of bed. In the hospital the client talks to unseen people and voids on the floor. The nurse could best handle the problem of voiding on the floor by
- A. Requiring the client to mop the floor
- B. Restricting the client's fluids throughout the day
- C. Withholding privileges each time the voiding occurs
- D. Toileting the client more frequently with supervision
Correct Answer: D
Rationale: Toileting the client more frequently with supervision. This approach addresses the physical need in a client with altered thought processes.
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When rendering aid to a victim who appears to be choking, the nurse's first action should be to:
- A. Administer a blow to the back.
- B. Ask the client whether she can speak.
- C. Administer a chest thrust.
- D. Establish an airway.
Correct Answer: B
Rationale: Asking if the victim can speak assesses airway obstruction severity. Back blows or chest thrusts follow if needed, and establishing an airway is not the first step.
The nurse in the emergency department is caring for a client who has facial lacerations, a suspected fracture of the arm, and multiple bruises at various stages of healing. The client's spouse is at the bedside and appears angry. Which of the following actions would be a priority for the nurse take?
- A. Recommend a referral to social services for the client.
- B. Talk with the client privately without the spouse in the room.
- C. Place the client's arm in a shoulder sling and prepare the client for an x-ray.
- D. Cleanse the client's facial lacerations and prepare to assist with suture placement.
Correct Answer: B
Rationale: Multiple bruises at various stages suggest possible abuse, so talking privately with the client (B) is the priority to assess safety. Social services (A) may follow, but immediate safety assessment comes first. Treating injuries (C, D) is secondary.
The nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place, and person and cannot follow directions or commands. Which intervention is most important when inserting the urinary catheter?
- A. Ensure the client understands the procedure prior to implementation
- B. Maintain a sterile field and keep the urinary catheter sterile
- C. Place the catheter supply kit between the client's legs in the center of the bed
- D. Throw swabs used to clean the perineum directly into the biohazard bin
Correct Answer: B
Rationale: Maintaining a sterile field (B) is critical to prevent infection, especially in a disoriented client. Explaining the procedure (A) is ideal but not feasible, kit placement (C) is secondary, and swab disposal (D) follows insertion.
The nurse is talking with a client who has type 1 diabetes mellitus and is receiving newly prescribed continuous subcutaneous insulin infusion therapy via an infusion pump. Which of the following statements by the client would indicate a correct understanding of the therapy?
- A. I will no longer need to test my blood glucose level throughout the day.
- B. I will no longer require an extra dose of insulin before my meals.
- C. My blood glucose levels should be more consistent throughout the day.
- D. The infusion set of my insulin pump should be changed daily.
Correct Answer: C
Rationale: Insulin pumps (C) provide steady insulin delivery, improving glucose stability. Glucose monitoring (A) and bolus doses (B) are still needed, and infusion sets are changed every 2-3 days, not daily (D).
The nurse is caring for a client with a tracheostomy who has an order to begin oral intake. Which of the following actions should the nurse take to decrease the client's risk for aspiration?
- A. Fully inflate the tracheostomy cuff before the client begins to eat.
- B. Encourage the client to use a straw when drinking fluids.
- C. Instruct the client to tilt the head back when swallowing
- D. Provide thickened liquids for the client.
Correct Answer: D
Rationale: Thickened liquids (D) reduce aspiration risk by slowing transit. Inflating the cuff (A) is not always necessary, straws (B) may increase risk, and tilting the head back (C) worsens aspiration.