Nokea
A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Apply the belt restraint over the client's gown.
- B. Check the client's skin integrity every 4 hr.
- C. Tie the belt restraint to the side rail of the bed.
- D. Make sure four fingers fit between the restraint and the client's body.
Correct Answer: A
Rationale: Applying the restraint over the gown prevents skin irritation and ensures proper fit per safety guidelines.
You may also like to solve these questions
A nurse in a provider's office is collecting data from an older adult client. The client states that he is having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?
- A. Take a 1-hour nap each day.
- B. Watch television in bed.
- C. Drink a glass of milk before bedtime.
- D. Take a long walk before bedtime.
Correct Answer: C
Rationale: Milk contains tryptophan, which promotes sleep; other options may disrupt sleep patterns.
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?
- A. The stoma is draining a small amount of liquid stool.
- B. The stoma protrudes slightly from the abdomen.
- C. The stoma bleeds lightly when touched.
- D. The stoma appears dark in color.
Correct Answer: D
Rationale: A dark stoma indicates potential necrosis or ischemia, requiring immediate provider attention.
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?
- A. Add 0.5 mL of diluent to the medication.
- B. Use a filter needle to aspirate the medication.
- C. Inject air into the ampule prior to drawing the medication into a syringe.
- D. Cleanse the tip of the ampule with an alcohol swab after opening.
Correct Answer: B
Rationale: A filter needle prevents glass particles from being drawn into the syringe from the ampule.
A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I drink two hot cups of coffee each morning.
- B. I love to eat apples and black-eyed peas.
- C. I take a prescribed opioid pain medication at bedtime.
- D. I drink an average of 2,000 milliliters of water daily.
Correct Answer: C
Rationale: Opioids slow gastrointestinal motility, increasing the risk of constipation and impaired bowel elimination.
A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. Family history of osteoporosis
- B. Type 1 diabetes mellitus
- C. Orthostatic hypotension
- D. BMI of 24
Correct Answer: B
Rationale: Type 1 diabetes increases cardiovascular risk due to chronic hyperglycemia affecting blood vessels.