Nokea
A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)
- A. Keep a night light on in the client's room and bathroom.
- B. Keep the bed at a comfortable working height.
- C. Lock the wheels on beds and wheelchairs during transfers.
- D. Place the bedside table within the client's reach.
- E. Administer a sedative at bedtime.
Correct Answer: A,C,D
Rationale: The correct actions to contribute to the fall prevention plan are A, C, and D. A night light can help the client see clearly at night, reducing the risk of tripping. Locking the wheels on beds and wheelchairs ensures stability during transfers. Placing the bedside table within reach promotes independence and prevents falls from reaching for items. Choice B is incorrect as bed height doesn't directly impact fall risk. Choice E, administering a sedative, can increase fall risk due to drowsiness.
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A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
- A. Cool skin
- B. Bradycardia
- C. Urine output 20 mL/hr
- D. Sodium 142 mEq/L
Correct Answer: C
Rationale: The correct answer is C: Urine output 20 mL/hr. In dehydration, the body tries to conserve water, leading to decreased urine output. This finding indicates the body's attempt to retain fluids. A: Cool skin is incorrect as dehydration often presents with warm, dry skin due to decreased sweating. B: Bradycardia is unlikely in dehydration as the body tries to maintain cardiac output by increasing heart rate. D: A normal sodium level of 142 mEq/L does not specifically indicate dehydration.
A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
- A. Count the apical pulsations for a full minute.
- B. Check the apical pulse with a Doppler device.
- C. Use the diaphragm of the stethoscope to listen to the apical pulsations.
- D. Press the stethoscope firmly against the client's skin.
Correct Answer: A
Rationale: The correct answer is A: Count the apical pulsations for a full minute. This is because counting the apical pulse for a full minute provides the most accurate assessment of the client's heart rate. It allows for any irregularities or fluctuations in the pulse to be detected.
Choice B is incorrect as using a Doppler device is not necessary for routine assessment of the apical pulse. Choice C is incorrect as the bell of the stethoscope, not the diaphragm, should be used to listen to the apical pulsations for better sound transmission. Choice D is incorrect as pressing the stethoscope firmly against the client's skin can create artifact noise and interfere with accurate auscultation.
A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?
- A. Cracks in oral mucous membranes
- B. Poor skin turgor
- C. Tachycardia
- D. Excessive pulmonary secretions
Correct Answer: C
Rationale: Tachycardia can indicate oxygen toxicity. Other symptoms include confusion and restlessness. Pulmonary secretions are expected in pneumonia, not a sign of toxicity.
A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?
- A. Discontinue the enema.
- B. Lower the height of the solution bag.
- C. Continue the enema and reassure the client.
- D. Pause the enema and give the client pain medication.
Correct Answer: B
Rationale: Correct Answer: B - Lower the height of the solution bag.
Rationale: Lowering the height of the solution bag will decrease the flow rate of the enema, which can help alleviate the mild cramping the client is experiencing. This adjustment can make the procedure more tolerable for the client without needing to discontinue it entirely. It is important to address the client's discomfort while ensuring the effectiveness of the enema.
Summary of other choices:
A: Discontinuing the enema may not be necessary if the client's discomfort can be managed with a simple adjustment.
C: Continuing the enema without addressing the client's discomfort may lead to increased distress.
D: Pausing the enema and giving pain medication is not the initial intervention for mild cramping and may not be necessary if a simple adjustment can alleviate the discomfort.
A nurse is caring for a client who has diabetes mellitus and had a below-the-knee amputation 2 days ago. Which of the following statements by the client should the nurse identify as an indication that the client has a body image disturbance?
- A. When I look in the mirror, all I see is a person without a leg.
- B. I have not always made good choices in life. I deserve to lose my leg.
- C. If my wife had paid more attention to my blood sugar levels I would not have needed an amputation.
- D. No matter how hard I work in physical therapy, I can't seem to make any progress.
Correct Answer: A
Rationale: A body image disturbance is reflected in the client's negative perception of their physical self.