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A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)
- A. Provide diversionary activities for the client.
- B. Assist the client with toileting at frequent intervals.
- C. Involve the family in the client’s care.
- D. Explain to the client that he will be restrained if he does not stop pulling on his NG tube.
- E. Use an electronic bed alarm device.
Correct Answer: A,B,C,E
Rationale: The correct actions are A, B, C, and E. A) Providing diversionary activities can distract the client from pulling on the NG tube. B) Assisting with toileting at frequent intervals helps address any discomfort or restlessness that may be contributing to the behavior. C) Involving the family can provide additional support and understanding of the client's needs. E) Using an electronic bed alarm device can alert the nurse when the client is attempting to pull on the NG tube, allowing for timely intervention. These actions focus on addressing the underlying reasons for the behavior and ensuring the client's safety without resorting to restraints, which should be a last resort due to ethical and legal considerations.
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A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate 18/min.
- B. Blood pressure 102/66 mm Hg.
- C. Yellow-green drainage on the surgical incision.
- D. Straw-colored urine from an indwelling urinary catheter.
Correct Answer: C
Rationale: The correct answer is C because yellow-green drainage on the surgical incision can indicate an infection, which is a critical postoperative complication that requires immediate attention from the provider. This finding suggests the presence of pus or other infectious material in the wound, increasing the risk of further complications like wound dehiscence or systemic infection. Reporting this to the provider promptly allows for timely intervention such as wound exploration, debridement, and initiation of appropriate antibiotics.
The other choices are not as concerning in the immediate postoperative period:
A: Respiratory rate within normal range
B: Blood pressure within normal range
D: Straw-colored urine is expected from an indwelling urinary catheter, indicating adequate kidney function and hydration.
A nurse is preparing to administer ziprasidone 10 mg IM every 6 hr. Available is ziprasidone 20 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.5
Rationale: The correct answer is 0.5 mL. To calculate this, first determine the total dose needed per administration (10 mg). Then, divide the total dose by the concentration of the medication (20 mg/mL) to find the volume to administer per dose (10 mg ÷ 20 mg/mL = 0.5 mL). This ensures the patient receives the correct amount of medication. Other choices are incorrect because they do not accurately calculate the volume needed for the specified dose. For example, choosing a higher volume would result in overdosing the patient, while choosing a lower volume would underdose the patient. The correct calculation is essential to ensure the patient's safety and therapeutic effectiveness.
A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?
- A. Check the circulation of the affected extremity.
- B. Administer additional pain medication.
- C. Reposition the affected extremity.
- D. Document the findings.
Correct Answer: A
Rationale: The correct answer is A: Check the circulation of the affected extremity. This should be the first action because the client's pain is unrelieved by medication, indicating a potential circulation issue that needs immediate attention to prevent complications like compartment syndrome. Checking circulation involves assessing for skin color, temperature, capillary refill, pulse, and sensation. Administering more pain medication (B) without addressing the underlying cause may mask symptoms and delay proper treatment. Repositioning the extremity (C) may worsen the condition if circulation is compromised. Documenting the findings (D) is important but not the priority when the client is experiencing severe unrelieved pain.
A nurse in a clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client?
- A. Use friction when washing the affected area.
- B. Use a new cosmetic pad with each limited application of makeup.
- C. Use an oil-based soap to wash affected areas daily.
- D. Express the larger comedones periodically.
Correct Answer: B
Rationale: The correct answer is B: Use a new cosmetic pad with each limited application of makeup. This is important to prevent the spread of bacteria and reduce the risk of exacerbating acne. Using a new pad each time helps to avoid introducing more bacteria to the skin. Choice A is incorrect because friction can irritate the skin and worsen acne. Choice C is incorrect as oil-based soap can clog pores and worsen acne. Choice D is incorrect because expressing comedones can lead to scarring and infection. It's crucial to provide accurate and evidence-based information to clients to promote effective management of their condition.
A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?
- A. Eating a high fiber diet will reduce my risk for developing skin cancer.
- B. I should check my skin monthly for any changes.
- C. I should avoid the use of tanning booths.
- D. I should use sunscreen even on cloudy days.
- E. I should use sunscreen even on cloudy days.
Correct Answer: A
Rationale: The correct answer is A. Eating a high fiber diet does not directly reduce the risk of developing skin cancer. The other choices are more directly related to preventing skin cancer, such as checking skin for changes (B), avoiding tanning booths (C), and using sunscreen on both sunny and cloudy days (D and E). Therefore, further teaching is needed to clarify the misconception about the role of a high fiber diet in preventing skin cancer.