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. Secure the restraints with a square knot.
- B. Check the client's range of motion every 6 hr.
- C. Make sure two fingers fit under the restraints.
- D. Request a prescription renewal from the provider every 36 hr.
Correct Answer: C
Rationale: Ensuring two fingers fit prevents excessive tightness, promoting circulation and safety.
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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. Provide the client with finger foods for meals.
- C. Restrict visitors during meals.
- D. Provide the client with three large meals each day.
Correct Answer: B
Rationale: Finger foods simplify eating for dementia patients, encouraging intake despite utensil challenges.
A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
- A. Inflate the catheter's balloon.
- B. Lower the penis to a 45° angle.
- C. Apply lidocaine gel to the urethra.
- D. Twist the catheter gently.
Correct Answer: D
Rationale: Gentle twisting can navigate urethral obstructions safely without causing trauma.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 12.5 mL
Rationale: 55 lb = 25 kg; 25 kg × 50 mg/kg/day = 1250 mg/day; 1250 mg ÷ 4 = 312.5 mg/dose; 312.5 mg ÷ (125 mg/5 mL) = 12.5 mL.
A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Reposition the client once every 4 hr.
- B. Use a fan to circulate air in the client's room.
- C. Place the head of the client's bed flat.
- D. Provide oral care to the client once every 8 hr.
Correct Answer: B
Rationale: A fan reduces breathlessness sensation, improving comfort in dyspnea.
A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
- A. How will you discuss this decision with your loved ones?
- B. Your quality of life will be compromised if you make this decision.
- C. We should talk about your decision later.
- D. Don't worry. Everything will work out for you.
Correct Answer: A
Rationale: This response supports the client’s autonomy and facilitates discussion about their decision.