Nokea
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first?
- A. Lower the client to the floor.
- B. Obtain the client's vital signs.
- C. Loosen the client's restrictive clothing.
- D. Clear items from the client's surrounding are
Correct Answer: D
Rationale: The correct action to take first when caring for a client experiencing a seizure is to clear items from the client's surrounding area (Choice D). This is important to prevent injury to the client during the seizure. By removing objects that could cause harm, such as sharp or hard items, the nurse ensures a safe environment for the client. Lowering the client to the floor (Choice A) is important but should be done after clearing the surroundings to prevent injury. Obtaining vital signs (Choice B) and loosening restrictive clothing (Choice C) can be done after ensuring the safety of the environment. Thus, the priority is to clear items from the client's surrounding area to prevent harm during the seizure.
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A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse make?
- A. Twist at the waist when standing from a seated position.'
- B. Use a raised toilet seat to maintain your hips above your knees.'
- C. Apply a heating pad to the operative hip to decrease pain.'
- D. Move your stronger leg first when using a walker.'
Correct Answer: B
Rationale: The correct answer is B: Use a raised toilet seat to maintain your hips above your knees. This is important post-total hip arthroplasty to prevent hip dislocation. By keeping the hips above the knees, it reduces stress on the hip joint.
Incorrect choices:
A: Twisting at the waist can strain the hip joint post-surgery.
C: Applying heat can increase inflammation and risk of infection.
D: Moving the stronger leg first can lead to uneven weight distribution, increasing the risk of falls.
A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line in her left forearm. The client is receiving an antibiotic via intermittent IV bolus every 12 hr. Which of the following actions should the nurse take in managing the client's PICC line?
- A. Access the catheter using a non-coring needle.
- B. Change the transparent membrane dressing daily.
- C. Maintain a continuous IV infusion through the PICC line.
- D. Flush the catheter with a 0.9% sodium chloride solution after each use.
Correct Answer: D
Rationale: Correct Answer: D - Flush the catheter with a 0.9% sodium chloride solution after each use.
Rationale: Flushing the catheter with 0.9% sodium chloride solution after each use helps prevent clot formation, maintains patency, and ensures proper functioning of the PICC line. This action also helps prevent infection and occlusions.
Incorrect Choices:
A: Accessing the catheter using a non-coring needle is not necessary for routine care of a PICC line.
B: Changing the transparent membrane dressing daily may increase the risk of infection and disrupt the integrity of the dressing.
C: Maintaining a continuous IV infusion through the PICC line is not indicated for a client receiving intermittent IV bolus antibiotics.
E, F, G: No additional choices provided.
A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?
- A. Standard precautions
- B. Airborne precautions
- C. Contact precautions
- D. Droplet precautions
Correct Answer: B
Rationale: The correct answer is B: Airborne precautions. Tuberculosis is transmitted through the air via droplet nuclei. Implementing airborne precautions includes wearing an N95 respirator, placing the client in a negative pressure room, and ensuring proper ventilation. Standard precautions (A) are for all clients, contact precautions (C) are for direct contact with the client or their environment, and droplet precautions (D) are for pathogens transmitted through respiratory droplets. Therefore, implementing airborne precautions is crucial to prevent the spread of tuberculosis.
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and has a referral for dietary consult. The client tells the nurse, 'I will have to eat whatever the dietitian tells me.' Which of the following statements by the nurse encourages the client's involvement in their plan of care?
- A. The dietitian will provide you with the best food choices to manage your diabetes.'
- B. I understand that the dietary choices can seem overwhelming.'
- C. I can assist you with making a list of foods you like for the dietitian.'
- D. Managing your diabetes will require you to make accommodations.'
Correct Answer: C
Rationale: The correct answer is C because it encourages the client's involvement in their plan of care by actively engaging them in the decision-making process. By offering to assist the client in making a list of foods they like for the dietitian, the nurse is promoting client autonomy and empowerment. This approach helps the client feel more in control of their dietary choices and encourages collaboration between the client, nurse, and dietitian.
Choice A is incorrect as it does not actively involve the client in decision-making. Choice B acknowledges the client's feelings but does not directly engage them in the process. Choice D focuses on the client's responsibilities but does not promote active participation.
A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room?
- A. NG tube
- B. Tongue blade
- C. Wrist restraints
- D. Oral airway
Correct Answer: D
Rationale: The correct answer is D: Oral airway. During a seizure, a client may experience difficulty breathing due to their airway being obstructed. Placing an oral airway helps maintain a clear airway, ensuring adequate oxygenation. NG tube (A) is not relevant to managing seizures. Tongue blade (B) can cause injury during a seizure. Wrist restraints (C) are not appropriate and can increase the risk of injury.