Nokea
A nurse in a mental health facility receives a change-of-shift report on four clients. Which of the following clients should the nurse assess first?
- A. Client placed in restraints for aggressive behavior
- B. A new client with a history of a 4.5 kg weight loss in the past two months
- C. Client who received a PRN dose of haloperidol 2 hours ago for increased anxiety
- D. Client who will be receiving his first ECT treatment today
Correct Answer: A
Rationale: A client in restraints due to aggressive behavior needs immediate assessment to ensure safety and well-being. The nurse should assess this client first to address any potential risks, such as circulation issues, skin integrity problems, and ongoing agitation. Choices B, C, and D do not present immediate safety concerns that require urgent assessment compared to a client restrained for aggressive behavior.
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A nurse is obtaining the medical history of a client who has a new prescription for isosorbide mononitrate. Which of the following should the nurse identify as a contraindication to this medication?
- A. Glaucoma
- B. Hypertension
- C. Polycythemia
- D. Migraine headaches
Correct Answer: A
Rationale: Isosorbide mononitrate is contraindicated in clients with glaucoma due to its potential to increase intraocular pressure, which can exacerbate the condition. Hypertension, polycythemia, and migraine headaches are not contraindications for isosorbide mononitrate. In fact, isosorbide mononitrate is commonly used in the management of hypertension and certain types of angina.
While caring for a newborn under phototherapy lights, what is an appropriate nursing action?
- A. Ensure an eye shield is covering the eyes
- B. Apply lotion to the exposed skin
- C. Offer glucose water between feedings
- D. Discontinue breastfeeding during treatment
Correct Answer: A
Rationale: The correct answer is to ensure an eye shield is covering the eyes. This action is essential to protect the newborn's eyes from the bright light used in phototherapy. Applying lotion to the exposed skin (Choice B) is not necessary and may interfere with the treatment. Offering glucose water between feedings (Choice C) is not indicated and may not be appropriate for a newborn undergoing phototherapy. Discontinuing breastfeeding during treatment (Choice D) is not recommended as breastfeeding should be continued unless contraindicated.
A healthcare provider is assessing a client for allergies before administering propofol. Which of the following allergies is a contraindication to the medication?
- A. Eggs
- B. Milk
- C. Shrimp
- D. Peanuts
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A charge nurse is providing teaching to a newly licensed nurse on how to clean surfaces contaminated with blood. Which of the following agents should the nurse include in the teaching?
- A. Hydrogen peroxide
- B. Chlorhexidine
- C. Isopropyl alcohol
- D. Chlorine bleach
Correct Answer: D
Rationale: Chlorine bleach is the recommended agent for cleaning blood spills due to its effectiveness in killing bloodborne pathogens like HIV and hepatitis B. Hydrogen peroxide, Chlorhexidine, and Isopropyl alcohol are not as effective as chlorine bleach in disinfecting surfaces contaminated with blood and eliminating bloodborne pathogens, making them incorrect choices.
A nurse is caring for a client who has DVT. Which of the following instructions should the nurse include in the plan of care?
- A. Limit the client's fluid intake to 1500 mL per day
- B. Massage the affected extremity to relieve pain
- C. Apply cold packs to the affected extremity
- D. Elevate the client's affected extremity when in bed
Correct Answer: D
Rationale: The correct instruction the nurse should include in the plan of care for a client with DVT is to elevate the affected extremity when in bed. Elevating the affected extremity helps improve venous return, reduces edema, alleviates discomfort, and promotes healing in clients with DVT. Limiting fluid intake can be detrimental as adequate hydration is important for circulation. Massaging the affected extremity can dislodge clots and worsen the condition. Applying cold packs can cause vasoconstriction, which is not recommended for DVT as it can impede blood flow further.