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A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?
- A. Use a bed exit alarm system.
- B. Raise four side rails while the client is in bed.
- C. Apply one soft wrist restraint.
- D. Dim the lights in the client's room.
Correct Answer: A
Rationale: The correct answer is A: Use a bed exit alarm system. This intervention is crucial in minimizing the risk of injury for a client with dementia as it alerts the nurse when the client attempts to get out of bed, preventing falls. This approach promotes client safety by allowing timely intervention. Raising four side rails (B) may restrict the client's movement and cause agitation or attempts to climb over the rails, increasing the risk of injury. Applying a soft wrist restraint (C) is considered a restrictive measure and should be avoided unless absolutely necessary due to the risk of causing emotional distress and physical harm to the client. Dimming the lights (D) in the client's room may increase confusion and disorientation, leading to a higher risk of falls.
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A nurse is caring for a client who has pancreatitis. Select the 3 tasks the nurse should delegate to an assistive personnel (AP). First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia, Pulses to lower extremities weak with +2 dependent edema present, Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this am. States voiding without difficulty, clear yellow urine. Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle changes for heart failure. Provided medication teaching following provider's increase in furosemide dosage from.
- A. Document the client's vital signs.
- B. Measure the client's intake and output.
- C. Transfer the client from wheelchair to bed.
- D. Insert an NG tube for the client.
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Documenting vital signs is within the scope of practice for an assistive personnel (AP) as it involves measuring and recording objective data.
B: Measuring intake and output is a task that can be safely delegated to the AP as it requires basic monitoring skills and doesn't involve complex decision-making.
C: Transferring the client from a wheelchair to bed is a physical task that can be delegated to the AP, as long as proper body mechanics are used to prevent injury.
Summary:
D: Inserting an NG tube is a skilled nursing task that requires specialized training and should not be delegated to an AP.
E: No task provided for this option.
F: No task provided for this option.
G: No task provided for this option.
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?
- A. Verify the client's name on their identification bracelet with the medication administration record.
- B. Call the pharmacy to determine whether the client's medications are available.
- C. Compare the client's home medications with the provider's prescriptions.
- D. Place the client's home medication bottles in a secure location.
Correct Answer: C
Rationale: The correct answer is C: Compare the client's home medications with the provider's prescriptions. This is essential for medication reconciliation to ensure accuracy and prevent medication errors. By comparing the client's home medications with the provider's prescriptions, the nurse can identify discrepancies, address any missing medications or duplications, and ensure the client receives the correct treatment. Verifying the client's name (A) is important for patient safety but not directly related to medication reconciliation. Calling the pharmacy (B) may provide some information but does not involve comparing home medications with provider prescriptions. Placing home medication bottles in a secure location (D) is not part of the medication reconciliation process.
A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?
- A. Examine personal values about the issue.
- B. Tell the parents that this is a necessary procedure.
- C. Inform the parents that the staff does not require their consent.
- D. Contact a spiritual support person to explain the importance of the procedure.
Correct Answer: A
Rationale: The correct answer is A: Examine personal values about the issue. The nurse should first reflect on their own values to ensure they can provide care without bias. This allows the nurse to approach the situation with empathy and understanding. Choice B is incorrect because it disregards the parents' beliefs. Choice C is incorrect as parental consent is typically required for medical procedures involving minors. Choice D may not be effective as it may come across as disrespectful to the parents' beliefs.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
- A. Position the client at the head of the bed elevated to 30° prior to insertion of the NG tube.
- B. Remove the NG tube if the client begins to gag or choke.
- C. Apply suction to the NG tube prior to insertion.
- D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Having the client take sips of water serves to promote the insertion of the NG tube into the esophagus by facilitating swallowing and opening the esophageal sphincter, making it easier to pass the tube through. This action helps ensure proper placement of the tube in the stomach without risking insertion into the trachea or lungs.
Summary of other choices:
A: Positioning the client at the head of the bed elevated to 30° is important but is not directly related to the insertion of the NG tube.
B: Removing the NG tube if the client gags or chokes is incorrect as these are common responses during insertion, and removing the tube may lead to premature discontinuation.
C: Applying suction to the NG tube prior to insertion is unnecessary and may cause discomfort or damage to the mucosa.
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?
- A. I will return shortly after I document this in your record.
- B. Most men live a long time with prostate cancer.
- C. I am available to talk if you should change your mind.
- D. I will make a referral to a cancer support group for you.
Correct Answer: C
Rationale: The correct answer is C: "I am available to talk if you should change your mind." This response shows the nurse's willingness to provide support and maintain an open line of communication without being intrusive. It respects the client's current decision while also conveying availability for future discussions, promoting trust and rapport.
A: Incorrect. This response prioritizes documentation over the client's emotional needs.
B: Incorrect. While well-intentioned, this statement may offer false reassurance and overlooks individual variability in prognosis.
D: Incorrect. Referring to a support group without the client's consent may not align with their current preferences.
E: Incorrect. Incomplete choice.
F: Incorrect. Incomplete choice.
G: Incorrect. Incomplete choice.