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A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?
- A. Evaluate the need for the client to remain in mitten restraints.
- B. Determine the circulation status of the affected extremities every 2 hr.
- C. Instruct the client's family about the purpose of mitten restraints.
- D. Assist the client with range-of-motion exercises of the hands.
Correct Answer: D
Rationale: Assisting with range-of-motion is within the AP's scope, unlike evaluation or teaching.
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The preschooler has manifestations of respiratory syncytial virus.
A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus. Which of the following actions should the nurse take?
- A. Administer fluconazole to the preschooler.
- B. Monitor the preschooler's urine for protein.
- C. Request an x-ray of the preschooler's neck.
- D. Initiate droplet precautions.
Correct Answer: D
Rationale: Droplet precautions prevent RSV transmission.
The client has mild hypertension.
A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should exercise for 15 minutes two times per week.
- B. I should decrease my salt intake to 2 grams per day.
- C. I will set my blood pressure goal at 130 over 84.
- D. I can have two glasses of wine with dinner.
Correct Answer: B
Rationale: Reducing salt to 2 grams daily helps manage hypertension, showing understanding.
The client reports manifestations of depression.
A nurse is collecting data from a client who reports manifestations of depression. Which of the following findings should the nurse identify as a risk factor for suicide?
- A. The client is married and has children.
- B. The client has a strong religious affiliation.
- C. The client recently received a pay raise at work.
- D. The client has a history of chronic back pain.
Correct Answer: D
Rationale: Chronic pain increases suicide risk due to persistent distress.
A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? (Select all that apply)
- A. Instruct another nurse to record the prescription in the medical record.
- B. Ask the provider to spell out the name of the medication.
- C. Withhold the medication until the provider signs the prescription.
- D. Record the date and time of the telephone prescription.
- E. Request that the provider confirm the read-back of the prescription.
Correct Answer: B,D,E
Rationale: Spelling the medication, recording date/time, and confirming read-back ensure accuracy and safety.
The partner of a client who is receiving hospice care.
A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for pain management. Which of the following statements by the partner indicates an understanding of the teaching?
- A. My husband won't need medication for breakthrough pain while using music therapy.
- B. I will discontinue music therapy when my husband is no longer responsive.
- C. Playing music will increase my husband's alertness.
- D. Music will distract my husband's awareness of the pain.
Correct Answer: D
Rationale: Music therapy distracts from pain perception, aiding management.