Nokea
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. Check the client's range of motion every 6 hr.
- B. Make sure two fingers fit under the restraints.
- C. Secure the restraints with a square knot.
- D. Request a prescription renewal from the provider every 36 hr.
Correct Answer: B
Rationale: Ensuring two fingers fit under restraints prevents excessive tightness and maintains circulation.
You may also like to solve these questions
A nurse is caring for a client and observes a nurse from another unit reviewing the client's medical record. Which of the following actions should the nurse take?
- A. Contact facility security to remove the nurse from the unit.
- B. Complete an incident report about the breach of confidentiality.
- C. Remind the nurse that only staff caring for the client may access the client's record.
- D. Tell the nurse that permission from the risk manager is required to view the client's record.
Correct Answer: C
Rationale: Reminding the nurse about confidentiality reinforces HIPAA compliance without escalating unnecessarily.
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. Limit snacks between meals.
- B. Restrict visitors during meals.
- C. Provide the client with three large meals each day.
- D. Provide the client with finger foods for meals.
Correct Answer: D
Rationale: Finger foods are easier for dementia clients to manage, encouraging self-feeding and intake.
A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client verbalizes regret about never marrying.
- B. The client has poorly fitting dentures.
- C. The client has no living family.
- D. The client is sedentary throughout most of the day.
Correct Answer: B
Rationale: Poorly fitting dentures impair nutrition, a priority health risk requiring immediate attention.
A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps, placing them in the order of performance.)
- A. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
- B. Open each side flap of the sterile kit individually while pulling to the side.
- C. Prepare a dry work surface above the waist level.
- D. Open the outside cover of the sterile kit and remove the dust cover.
- E. Grasp the outermost flap of the sterile kit while opening away from the body.
Correct Answer: C,D,E,B,A
Rationale: C: Set up surface. D: Open cover. E: Open outermost flap. B: Open side flaps. A: Open innermost flap maintains sterility.
A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?
- A. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
- B. Keep the specimen in a warm area.
- C. Avoid placing toilet tissue in the bedpan after defecation.
- D. Urinate after the specimen collection.
Correct Answer: C
Rationale: Avoiding toilet tissue prevents contamination of the stool specimen with fibers or chemicals.