Nokea
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Observe the client's skin integrity every 2 hr.
- B. Use a square knot to secure the client's restraint to the bed.
- C. Ensure that 2 fingers can be placed between the restraint and the client.
- D. Tie the ends of the restraint to the client's bed rail.
- E. Pad bony prominences before applying a restraint.
Correct Answer: A,C,E
Rationale: A: Frequent skin checks prevent injury. C: Two fingers ensure proper fit. E: Padding protects bony areas.
You may also like to solve these questions
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Avoid the use of facial gestures during the instructions.
- B. Determine the client's ability to use a communication board.
- C. Speak with a loud voice while providing the information.
- D. Provide the teaching without expecting the client to respond.
Correct Answer: B
Rationale: A communication board can aid clients with expressive aphasia in understanding and responding.
Nurses' Notes
Vital Signs
Diagnostic Results
6 months ago:
Client present today for annual examination. Reports lack of sleep and increased stress due to moving and starting a new job.
Today, 1400:
Client presents to office today with reports of fatigue. Client states they have difficulty sleeping without drinking four or five beers a night. Client reports, "I sometimes get headaches along with nausea and vomiting. I have been busy with my new job, so I have been eating a lot of fast food, and I've gained 15 pounds."
Today, 1445.
Provider notified of laboratory results.
A nurse is assisting in the care of a client in a provider's office. A nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe?
- A. Administer a diuretic.
- B. Limit alcohol intake to 2 drinks per day.
- C. Keep daily fat intake to less than 35%
- D. Place on 2300 mg sodium diet.
- E. Administer an antibiotic
- F. Limit foods high in potassium.
Correct Answer: A, B, C, D
Rationale: A: Addresses fluid retention from fast food. B, C, D: Manage weight gain and hypertension risks.
A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?
- A. Cleanse the client's outer ear with isopropyl alcohol to remove wax.
- B. Pull the client's pinna downward and back.
- C. Hold the ear dropper 1 cm (0.5 in) from the client's ear.
- D. Request the client remain supine for 10 min following administration.
Correct Answer: C
Rationale: Holding the dropper 1 cm above prevents contamination and ensures proper delivery.
A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?
- A. Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field
- B. Opening the top flap of the sterile tray package away from their body
- C. Dropping sterile objects onto the field from a height of 5 cm (2 in)
- D. Placing the cap of a sterile solution on a clean surface with the inside facing down
Correct Answer: B
Rationale: Opening the flap away maintains sterility by keeping the nurse's body out of the field.
A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.
- A. Open the outside cover of the sterile kit and remove the dust cover
- B. Grasp the outermost flap of the sterile kit while opening away from the body.
- C. Prepare a dry work surface above the waist level
- D. Open the innermost lower flap of the sterile kit while standing away from the sterile field
- E. Open each side flap of the sterile kit individually while pulling to the side
Correct Answer: C, A, B, D, E
Rationale: Sequence maintains sterility: prepare surface, open kit, unfold flaps systematically.