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A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
- A. Document the client's behavior prior to being placed in seclusion.
- B. Assess the client's behavior once every hour.
- C. Offer fluids every 2 hours.
- D. Discuss with the client his inappropriate behavior prior to seclusion.
Correct Answer: A
Rationale: The correct answer is A because documenting the client's behavior before seclusion is essential for comprehensive care, ensuring accurate assessment, and treatment planning. This documentation provides crucial information for evaluating the effectiveness of seclusion, understanding triggers, and creating a safer environment. Assessing the client's behavior, offering fluids, or discussing inappropriate behavior are important but secondary to documenting behavior for legal, ethical, and continuity of care reasons. Monitoring behavior continuously is more effective than hourly assessments.
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A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?
- A. Examine for leakage at the site of the procedure.
- B. Compare the client's current weight with preprocedure weight.
- C. Confirm that the client is able to urinate.
- D. Check the client's serum albumin levels.
Correct Answer: B
Rationale: The correct answer is B: Compare the client's current weight with preprocedure weight. This is because paracentesis is a procedure used to remove fluid buildup in the abdomen, which can lead to weight loss. By comparing the client's current weight with the preprocedure weight, the nurse can evaluate the effectiveness of the procedure in draining the excess fluid. This comparison helps determine the amount of fluid removed and assess the client's response to the treatment.
Explanations for why the other choices are incorrect:
A: Examining for leakage at the site of the procedure is important for monitoring for potential complications but does not directly evaluate the effectiveness of the procedure.
C: Confirming that the client is able to urinate is important for assessing kidney function but does not specifically evaluate the effectiveness of the paracentesis.
D: Checking the client's serum albumin levels may provide information about the client's liver function and nutritional status but does not directly evaluate the effectiveness of the paracentesis procedure.
A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
- A. I will wait 15 minutes after drinking coffee to measure my blood pressure.
- B. I will measure my blood pressure while my arm is elevated above my heart.
- C. I should remove constrictive clothing prior to measuring my blood pressure.
- D. I should measure my blood pressure immediately after eating breakfast.
Correct Answer: C
Rationale: The correct answer is C: "I should remove constrictive clothing prior to measuring my blood pressure." Removing constrictive clothing ensures accurate blood pressure measurement by allowing the cuff to fit properly on the arm without any restrictions, leading to a more reliable reading. Choice A is incorrect as coffee can temporarily increase blood pressure. Choice B is incorrect because the arm should be at heart level, not elevated. Choice D is incorrect as blood pressure should be measured on an empty stomach for accuracy.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
- A. Remove the cap and place it sterile-side up on a clean surface.
- B. Place sterile gauze over areas of spilled solution within the sterile field.
- C. Hold the bottle in the center of the sterile field when pouring the solution.
- D. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Correct Answer: A
Rationale: The correct answer is A: Remove the cap and place it sterile-side up on a clean surface. This is essential to maintain the sterility of the solution and prevent contamination. Placing the cap sterile-side up ensures that the inside of the cap, which will come in contact with the solution again, remains sterile. Placing it on a clean surface prevents contamination from the surface. Options B, C, and D do not directly address maintaining the sterility of the solution. Option B is about spill management within the sterile field, which is important but not the primary concern when pouring the solution. Holding the bottle in the center (Option C) or with the label facing away (Option D) does not directly impact the sterility of the solution.
A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who is ambulatory and receiving oxygen
- B. A client who has a fracture and is in balance suspension traction
- C. A client who is bedridden and wears a hearing aid
- D. A client who uses a wheelchair and is confused
Correct Answer: A
Rationale: The correct answer is A: A client who is ambulatory and receiving oxygen should be evacuated first during a fire. This client has the highest risk due to the combination of mobility impairment and oxygen use, which increases the potential for rapid deterioration in a fire emergency. Oxygen supports combustion, making this client more vulnerable to fire-related injuries.
Choice B: A client with a fracture in balance suspension traction is stable and can wait for evacuation. Choice C: A bedridden client with a hearing aid can still hear evacuation instructions and wait for assistance. Choice D: A confused client in a wheelchair may require assistance but is not at immediate risk like the ambulatory client with oxygen.
A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?
- A. An angiocatheter
- B. A 25-gauge needle
- C. A butterfly needle
- D. A non-coring needle
Correct Answer: D
Rationale: The correct answer is D: A non-coring needle. This type of needle is specifically designed for accessing implanted venous access ports as it minimizes the risk of coring (removal of a piece of the septum) which can lead to complications. Using an angiocatheter (choice A) or a butterfly needle (choice C) can increase the risk of coring, causing damage to the port. A 25-gauge needle (choice B) is too small for accessing the port effectively. In summary, the non-coring needle is the optimal choice for accessing the port safely and effectively, while the other options pose risks of coring or inefficiency.