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. Make sure four fingers fit between the restraint and the client's body.
- B. Apply the belt restraint over the client's gown.
- C. Check the client's skin integrity every 4 hr.
- D. Tie the belt restraint to the side rail of the bed.
Correct Answer: B
Rationale: Applying over the gown prevents skin irritation and ensures proper fit.
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A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?
- A. Unequal height of the shoulders
- B. Expansion of the upper intercostal spaces
- C. Increased convex curve of the cervical spine
- D. Increased concave curve of the thoracic spine
Correct Answer: A
Rationale: Unequal shoulder height is a classic sign of scoliosis due to spinal curvature.
A nurse is preparing to perform a fecal occult blood test of stool specimens for a client. Which of the following actions should the nurse plan to take?
- A. Ensure that the stool specimen does not contain urine.
- B. Repeat the test three times using the same stool specimen.
- C. Have the client defecate into a bedpan that contains a small amount of water.
- D. Wear sterile gloves when handling the stool specimen
Correct Answer: A
Rationale: Urine can contaminate the specimen and affect test accuracy.
A nurse is assigning a semiprivate room to a client who has herpes zoster. Which of the following roommates is appropriate?
- A. A client who has rubella
- B. A client who has had varicella
- C. A client who is HIV-positive
- D. A client who has tuberculosis
Correct Answer: B
Rationale: A client with prior varicella is immune to herpes zoster, reducing transmission risk.
Nurses'Notes
Day 1:
Client reports to clinic following trip to emergency department (ED) after a fall at home. Reports slipping
on a floor rug and hurting left ankle.
ray report taken in ED shows left lateral malleolus fracture. Removable boot immobilizer in place, using
a cane for assistance in ambulating
Boot immobilizer removed, left ankle with edema +2. Client reports pain as 6 on a scale of 0 to 10.
Client states they were prescribed pain medication by ED provider. Client lives alone.
Reports being "down to 1⁄2 pack of cigarettes, least 3 cups of coffee daily. States their mother was
always breaking something.
Day 3:
Bone Mineral Density DEXA scan -3.8 (-1 or above)
Based on the client's laboratory and diagnostic results, indicate which of the following provider
prescriptions the nurse should expect.
A nurse in a provider's clinic is assisting in the care of an older adult female client.
For each provider prescription click to specify if the provider prescription is expected or unexpected for
the client. There must be at least 1 selection in every row. There does not need to be a selection in every
column.
- A. Physical therapy for muscle-strengthening and balance-training
- B. Calcium 1500 mg po once daily on empty stomach
- C. Vitamin D supplement 2,500 units daily
- D. Home health evaluation of home safety
- E. Increase caffeine intake
- F. Increase daily sun exposure
Correct Answer: A, B, C, D
Rationale: A: Improves strength and reduces fall risk. B, C: Address osteoporosis (DEXA -3.8). D: Ensures safe environment.
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Observe the client's skin integrity every 2 hr.
- B. Use a square knot to secure the client's restraint to the bed.
- C. Ensure that 2 fingers can be placed between the restraint and the client.
- D. Tie the ends of the restraint to the client's bed rail.
- E. Pad bony prominences before applying a restraint.
Correct Answer: A,C,E
Rationale: A: Frequent skin checks prevent injury. C: Two fingers ensure proper fit. E: Padding protects bony areas.