Nokea
A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with:
- A. Hypothyroidism
- B. Diabetic ulcers
- C. Ulcerative colitis
- D. Pneumonia
Correct Answer: A
Rationale: Hypothyroidism poses the least risk of infection or complications, making it the safest roommate choice for a surgical client.
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The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion?
- A. The security guard
- B. The registered nurse
- C. The licensed practical nurse
- D. The nursing assistant
Correct Answer: B
Rationale: An RN has the authority to initiate seclusion based on clinical judgment.
When administering a capsule that is individually wrapped to a client, when should the wrapping be removed?
- A. When initially obtained from the medicine cart
- B. When placed in the medicine cup
- C. Prior to entering the client's room
- D. At bedside in the client's presence
Correct Answer: D
Rationale: Removing the wrapping at the bedside (D) ensures the client sees the medication, enhancing safety and trust.
A diagnosis of multiple sclerosis is often delayed because of the varied symptoms experienced by those affected with the disease. Which symptom is most common in those with multiple sclerosis?
- A. Resting tremors
- B. Double vision
- C. Flaccid paralysis
- D. Pill-rolling tremors
Correct Answer: B
Rationale: Double vision (diplopia) is a common early symptom of multiple sclerosis due to demyelination affecting cranial nerves, particularly the optic and oculomotor nerves.
An older adult has become very confused after surgery for repair of a hip fracture. The client has repeatedly tried to climb over the bedrails and the nurse is considering placing the client in a Posey vest that is secured to the bed. Which of the following must the nurse consider when applying restraints to a client? Select all that apply.
- A. An alternate method should be tried prior to applying a restraint.
- B. Confused clients are almost always safer in restraints.
- C. Restraints must be removed and the client reassessed at least every 2 hours.
- D. A written policy for application of restraints must be in place.
- E. The most restrictive restraint should be applied.
- F. The nurse does not need an order for a restraint if the client is in danger.
Correct Answer: A,C,D
Rationale: Alternatives (A), reassessment every 2 hours (C), and a written policy (D) are required for restraints. Confused clients aren't always safer (B), most restrictive (E) is incorrect, and an order is needed (F).
While reviewing the chart of a client with a history of hepatitis B, the nurse finds a serologic marker of HBsAg. The nurse recognizes that the client:
- A. Has chronic hepatitis B
- B. Has recovered from hepatitis B infection
- C. Has immunity to infection with hepatitis C
- D. Has no chance of spreading the infection to others
Correct Answer: A
Rationale: Presence of HBsAg indicates active hepatitis B infection, either acute or chronic, and potential infectivity.