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A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is agitated. Which of the following interventions should the nurse implement?
- A. Administer a prescribed oral dose of trazodone to the client.
- B. Encourage the client to ambulate with a staff member.
- C. Isolate the client in their room.
- D. Apply bilateral wrist restraints to the client.
Correct Answer: A
Rationale: Prescribed trazodone addresses agitation pharmacologically. Other options are less effective or inappropriate for immediate management of agitation in Alzheimer's.
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A nurse is reinforcing teaching with a client who is taking enoxaparin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will use ibuprofen when I have a headache.
- B. I will use an electric razor for shaving
- C. I will avoid the use of stool softeners.
- D. I will massage the site after each injection.
Correct Answer: B
Rationale: Using an electric razor reduces bleeding risk with enoxaparin, an anticoagulant. Ibuprofen increases bleeding, stool softeners may be needed, and massaging injection sites is contraindicated.
A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is agitated. Which of the following interventions should the nurse implement?
- A. Administer a prescribed oral dose of trazodone to the client.
- B. Encourage the client to ambulate with a staff member.
- C. Isolate the client in their room.
- D. Apply bilateral wrist restraints to the client.
Correct Answer: A
Rationale: Trazodone, if prescribed, can calm agitation in Alzheimer's safely. Ambulation may help but isn't immediate, isolation can worsen agitation, and restraints are a last resort.
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A nurse is caring for a client who has deep-vein thrombosis. Which of the following interventions should the nurse plan to take?
- A. Place the client's bed in reverse Trendelenburg position.
- B. Massage the affected extremity every 4 hr.
- C. Apply cold compresses to the affected extremity.
- D. Measure the calf of the affected extremity each shift.
- E. Elevate the leg.
- F. Apply warm compresses.
- G. Administer heparin.
Correct Answer: D
Rationale: Measuring the calf monitors for swelling (worsening DVT); massage and cold can dislodge clots, and reverse Trendelenburg isn't specific.
A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?
- A. Replace the unit when the drainage chamber is full.
- B. Monitor for at least 150 mL of drainage every hour.
- C. Clamp the tube for 30 min every 8 hr.
- D. Pin the tubing to the client's bed sheets.
Correct Answer: A
Rationale: Chest tube systems remove pleural air or fluid, requiring functionality. Replacing the unit when full prevents backpressure or overflow, maintaining drainage and lung re-expansion, per manufacturer and infection control standards (e.g., CDC). Monitoring 150 mL/hr is excessive sudden high output signals hemorrhage, not routine care. Clamping risks tension pneumothorax by trapping air/fluid, only done briefly for specific checks (e.g., air leak). Pinning tubing prevents dislodgement, but full chamber replacement is the proactive maintenance action. This ensures system efficacy, prevents complications like atelectasis, and aligns with respiratory care priorities, making it the nurse's key responsibility.
A nurse is reinforcing teaching with a client who wants to lose 0.9 kg (2 lb) of body fat per week. The nurse knows that 0.45 kg (1 lb) of body fat is equal to 3500 calories. The nurse should instruct the client to reduce his daily caloric intake by how many calories?
Correct Answer: 1000
Rationale: Calculation: 2 lb × 3,500 cal/lb = 7,000 cal/week; 7,000 ÷ 7 = 1,000 cal/day reduction achieves the weight loss goal.