Nokea
A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?
- A. Place the bedside table 2 feet away from the bed.
- B. Keep lighting in the home dim.
- C. Place area rugs on slick floor surfaces.
- D. Move the client's bed to the main floor of the house.
Correct Answer: D
Rationale: Moving the bed to the main floor reduces stair-related fall risks.
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A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?
- A. Medications for a cardiac anomaly
- B. Chemotherapy treatments
- C. Two diarrhea stools in the last day
- D. Clear rhinorrhea
Correct Answer: B
Rationale: Chemotherapy suppresses immunity, contraindicating live vaccines like varicella.
A nurse on a mental health unit is caring for a client who is in restraints. Which of the following actions should the nurse take?
- A. Release the client's restraints every 4 hr.
- B. Check the client's status every hour.
- C. Obtain written consent by the client for the placement of the restraints.
- D. Document the client's behavior leading to the initiation of the restraints.
Correct Answer: D
Rationale: Documenting behavior justifies restraint use and meets legal standards.
The client reports feeling stress.
A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?
- A. Recurring urinary tract infections
- B. A recent move to a new city
- C. Report of feeling depressed
- D. Lack of nutritional knowledge
Correct Answer: B
Rationale: A recent move is an external stressor, unlike internal health or knowledge factors.
A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Measure the duration of the seizure
- B. Restrain the client's arms and legs to prevent injury
- C. Lower the side rails of the bed when the seizure begins
- D. Insert an oral airway into the client's mouth
Correct Answer: A
Rationale: Measuring duration aids in assessing seizure severity and planning care.
A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?
- A. Persistent uterine contractions
- B. Increased fetal movement
- C. Rigid abdomen
- D. Bright red vaginal bleeding
Correct Answer: D
Rationale: Bright red vaginal bleeding is characteristic of placenta previa.