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A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?
- A. Place the client in a sitting position.
- B. Tie the restraint to the railing of the client's bed.
- C. Ensure the restraint is placed across the client's chest.
- D. Apply the restraint under the client's clothes.
Correct Answer: A
Rationale: Placing the client in a sitting position ensures safety and proper restraint application.
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A nurse is reinforcing teaching with a client who is postoperative following a laparoscopic cholecystectomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should leave my steri-strips on until they fall off.
- B. I should expect to have nausea for several days.
- C. I should eat a high-fat diet for several weeks.
- D. I should expect to have diarrhea until my diet changes.
Correct Answer: A
Rationale: Leaving steri-strips on until they fall off promotes proper healing.
The client is visibly agitated and talking loudly in a group therapy session.
A nurse is caring for a client who is visibly agitated and talking loudly in a group therapy session. Which of the following actions should the nurse take first?
- A. Place the client in seclusion.
- B. Assist the client with understanding their needs.
- C. Ask the client to identify what made them upset.
- D. Administer lorazepam IM.
Correct Answer: C
Rationale: Identifying the trigger de-escalates agitation before further intervention.
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.
An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg.
A nurse is collecting data from a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg. Which of the following actions should the nurse take first?
- A. Remeasure the client's blood pressure.
- B. Administer an antihypertensive medication.
- C. Report the blood pressure reading to the charge nurse.
- D. Instruct the client to remain in bed.
Correct Answer: A
Rationale: Remeasuring verifies the accuracy of the elevated reading before further action.
The client is taking multiple medications and asks about possible interactions.
A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?
- A. Social worker
- B. Advanced practice nurse
- C. Patient care technician
- D. Psychologist
Correct Answer: B
Rationale: An advanced practice nurse can expertly assess medication interactions.