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A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client?
- A. Use disposable plates and utensils.
- B. Stay in a room with the door closed.
- C. Dispose of soiled dressings in plastic bags that are securely closed.
- D. Others who are in the same room with the client should wear a mask.
Correct Answer: C
Rationale: When a client is on contact precautions due to an infected draining wound, it is important to prevent contact with wound secretions. Therefore, disposing of soiled dressings in securely closed plastic bags helps contain and prevent the spread of infectious material, reducing the risk of transmission to others in the household.
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The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?
- A. Check the client's carotid pulse.
- B. Encourage the client to get to the toilet.
- C. In a loud voice, call for help.
- D. Gently lower the client to the floor.
Correct Answer: D
Rationale: The priority action for the nurse in this situation is to gently lower the client to the floor. This action helps prevent injury to both the client and the nurse. It is important to ensure a safe environment and protect the client from falling, as well as to maintain the nurse's own safety while providing care.
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?
- A. Loosen the right wrist restraint.
- B. Apply a pulse oximeter to the right hand.
- C. Compare hand color bilaterally.
- D. Palpate the right radial pulse.
Correct Answer: A
Rationale: The priority nursing action is to restore circulation by loosening the restraint (A) because blue fingers (cyanosis) indicate decreased circulation. Comparing hand color bilaterally (C) and palpating the right radial pulse (D) are important assessments to gather more information, but they do not have the priority of addressing the decreased circulation by loosening the restraint. Applying a pulse oximeter (B) is not indicated in this scenario as it measures the saturation of hemoglobin with oxygen, which is not relevant when cyanosis is related to mechanical compression from the restraints.
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next?
- A. Clamp the catheter and recheck it in 60 minutes.
- B. Pull the catheter back 3 inches and redirect it upward.
- C. Leave the catheter in place and reattempt with another catheter.
- D. Notify the healthcare provider of a possible obstruction.
Correct Answer: C
Rationale: In this scenario, if no urine is seen in the tubing after inserting the catheter, it is likely that the catheter is in the vagina rather than the bladder. Leaving the first catheter in place will help locate the meatus more easily when attempting the second catheterization. This approach ensures correct placement of the catheter in the bladder and minimizes the risk of causing unnecessary discomfort or trauma to the patient.
While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?
- A. Encourage the client to see the clinic's grief counselor.
- B. Determine if the client has a family history of suicide attempts.
- C. Inquire about whether the life partner had AIDS.
- D. Consult with the healthcare provider about the client's need for antidepressant medications.
Correct Answer: A
Rationale: The client is exhibiting symptoms of normal grief, such as flat affect, withdrawal, and sleep disturbances, following the recent death of his life partner. It is crucial for the nurse to encourage the client to see the clinic's grief counselor. Grief counseling can provide the client with appropriate support and coping strategies during this grieving process, helping him navigate through his loss and emotions effectively.
During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?
- A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing.
- B. The client tells the nurse that she does not have much of an appetite today.
- C. The nurse notes that there are numerous scatter rugs throughout the house.
- D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.
Correct Answer: C
Rationale: The presence of numerous scatter rugs throughout the house poses a significant safety hazard to the client who is ambulating with a quad cane. These rugs increase the risk of tripping and falling, making it the most critical finding that needs immediate attention to prevent potential injuries and ensure the client's safety during ambulation.