Nokea
A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?
- A. Sleep apnea
- B. Paresthesias
- C. Disorientation
- D. Tonic-clonic seizures
Correct Answer: C
Rationale: Disorientation is common shortly after ECT.
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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.
A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can have a meal up to 2 hours before the procedure.
- B. I should limit my fluid intake for 2 days after the procedure.
- C. I do not need to sign a consent form before this procedure.
- D. I will feel a warming sensation after the injection of the dye.
Correct Answer: D
Rationale: A warming sensation is expected with IVP dye injection, indicating understanding.
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.
The client is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy.
A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?
- A. Massage the affected extremity every 4 hr.
- B. Initiate bed rest.
- C. Apply an ice pack to the affected extremity for 20 min every 2 hr.
- D. Administer aspirin for pain.
Correct Answer: B
Rationale: Bed rest prevents dislodging the clot while on anticoagulants.
A nurse is assisting with teaching a class about the importance of fire safety. Which of the following hazards should the nurse include as an example of the leading cause of residential fires?
- A. Placing a space heater 5 ft from bed
- B. Smoking in bed
- C. Leaving the stove on
- D. Lack of smoke detectors
Correct Answer: B
Rationale: Smoking in bed is a leading cause of residential fires.