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A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Request a prescription renewal from the provider every 36 hr.
- B. Make sure two fingers fit under the restraints.
- C. Check the client's range of motion every 6 hr.
- D. Secure the restraints with a square knot.
Correct Answer: B
Rationale: Two fingers ensure the restraints are secure but not too tight.
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A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)
- A. Squeeze the client's finger until a blood drop forms.
- B. Prick the side of the client's finger.
- C. Elevate the client's hand above the level of the heart.
- D. Cleanse the client's finger with an iodine swab.
- E. Apply clean gloves.
Correct Answer: B,E
Rationale: B: Pricking the side is less painful and safer. E: Gloves prevent contamination and ensure safety.
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. Drink a glass of milk before bedtime.
- B. Watch television in bed.
- C. Take a long walk before bedtime.
- D. Take a 1-hour nap each day.
Correct Answer: A
Rationale: Milk contains tryptophan, which promotes sleepiness.
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. Use a filter needle to aspirate the medication.
- B. Inject air into the ampule prior to drawing the medication into a syringe.
- C. Cleanse the tip of the ampule with an alcohol swab after opening.
- D. Add 0.5 mL of diluent to the medication.
Correct Answer: A
Rationale: A filter needle prevents glass particles from entering the syringe.
A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?
- A. Provide the client with finger foods for meals.
- B. Restrict visitors during meals.
- C. Limit snacks between meals.
- D. Provide the client with three large meals each day.
Correct Answer: A
Rationale: Finger foods enhance self-feeding and intake in dementia clients.
A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, 'I'm not touching that thing.' Which of the following actions should the nurse take?
- A. Ask the client to explain her feelings.
- B. Request that someone from the client's family participate in the care.
- C. Explain why her participation is important.
- D. Tell the client that it is safe to touch her ostomy.
Correct Answer: A
Rationale: Asking about feelings shows empathy and helps address the client’s concerns.