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The client is visibly agitated and talking loudly in a group therapy session.
A nurse is caring for a client who is visibly agitated and talking loudly in a group therapy session. Which of the following actions should the nurse take first?
- A. Place the client in seclusion.
- B. Assist the client with understanding their needs.
- C. Ask the client to identify what made them upset.
- D. Administer lorazepam IM.
Correct Answer: C
Rationale: Identifying the trigger de-escalates agitation before further intervention.
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A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? (Select all that apply)
- A. Instruct another nurse to record the prescription in the medical record.
- B. Ask the provider to spell out the name of the medication.
- C. Withhold the medication until the provider signs the prescription.
- D. Record the date and time of the telephone prescription.
- E. Request that the provider confirm the read-back of the prescription.
Correct Answer: B,D,E
Rationale: Spelling the medication, recording date/time, and confirming read-back ensure accuracy and safety.
The client has methicillin-resistant Staphylococcus aureus (MRSA).
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?
- A. Don gloves prior to assisting the client with brushing their teeth.
- B. Have the client wear a mask when they are out of their room.
- C. Ensure that the negative air pressure is active for the client's room.
- D. Place the client in a room with a high-efficiency particulate air (HEPA) filter.
Correct Answer: A
Rationale: Gloves prevent MRSA transmission during close contact like brushing teeth.
The client consumed alcohol 2 days after taking disulfiram.
A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?
- A. Constipation
- B. Dry skin
- C. Hypotension
- D. Urinary retention
Correct Answer: C
Rationale: Disulfiram-alcohol reaction causes hypotension among other symptoms.
A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?
- A. Believes the death is punishment for bad behavior
- B. Understands that everyone dies eventually
- C. Recognizes the parent will never wake up
- D. Expresses curiosity about the funeral service
Correct Answer: A
Rationale: Preschoolers often view death as punishment due to magical thinking.
A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?
- A. Place the client in a sitting position.
- B. Tie the restraint to the railing of the client's bed.
- C. Ensure the restraint is placed across the client's chest.
- D. Apply the restraint under the client's clothes.
Correct Answer: A
Rationale: Placing the client in a sitting position ensures safety and proper restraint application.