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A nurse is caring for a client with dementia who is at risk of falls. What is the most appropriate intervention?
- A. Use a bed exit alarm to notify staff of attempts to leave the bed
- B. Raise all four side rails for safety
- C. Encourage frequent ambulation with assistance
- D. Use restraints to prevent the client from getting out of bed
Correct Answer: A
Rationale: The most appropriate intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention allows for timely assistance and prevents falls. Raising all four side rails (Choice B) can lead to entrapment or agitate the client. Encouraging frequent ambulation with assistance (Choice C) may not be suitable for a client at high risk of falls. Using restraints (Choice D) should be avoided as they can increase agitation, risk of injury, and have ethical implications.
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A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has sinus arrhythmia and is receiving cardiac monitoring.
- B. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%.
- C. A client who has epidural analgesia and weakness in the lower extremities.
- D. A client who has a hip fracture and a new onset of tachypnea.
Correct Answer: D
Rationale: The correct answer is D. New onset of tachypnea indicates a potential respiratory complication that requires immediate attention. Assessing the client with a hip fracture and tachypnea first is crucial to address the respiratory issue and prevent further deterioration. Choices A, B, and C do not present immediate life-threatening complications that require urgent assessment compared to a new onset of tachypnea.
What are the signs of opioid withdrawal, and how should it be managed?
- A. Sweating, nausea; administer methadone
- B. Muscle cramps, vomiting; administer naloxone
- C. Tremors, sweating; administer buprenorphine
- D. Fever, agitation; provide sedatives
Correct Answer: A
Rationale: The signs of opioid withdrawal typically include sweating and nausea. The correct management approach involves administering methadone to alleviate the symptoms. Choice B is incorrect because naloxone is used to reverse opioid overdose, not for managing withdrawal symptoms. Choice C is incorrect as buprenorphine is typically used to treat opioid addiction, not just withdrawal symptoms. Choice D is incorrect as sedatives are not the primary treatment for opioid withdrawal.
A client needs a 24-hour urine collection initiated. Which of the following client statements indicates an understanding of the procedure?
- A. I had a bowel movement, but I was able to save the urine.
- B. I have a specimen in the bathroom from about 30 minutes ago.
- C. I flushed what I urinated at 7 am and have saved the rest since.
- D. I drink a lot, so I will fill up the bottle and complete the test quickly.
Correct Answer: C
Rationale: Choice C is correct because it demonstrates the client's understanding of the procedure, which involves discarding the first urine of the day at the specified time and then saving all subsequent urine for the next 24 hours. Choices A, B, and D do not reflect an understanding of the correct procedure. Choice A is incorrect because bowel movements are not part of a 24-hour urine collection. Choice B is incorrect as it does not specify discarding the first urine. Choice D is incorrect as it mentions filling up the bottle quickly, which is not the correct way to collect a 24-hour urine sample.
A client scheduled to begin chemotherapy is discussing alopecia with a nurse. Which of the following statements should the nurse make?
- A. Avoid washing your hair during treatment
- B. Your oncologist might prescribe a cold cap during treatment to reduce hair loss
- C. You'll need to apply sunscreen to the scalp
- D. You'll likely experience regrowth of hair within 6 months after treatment ends
Correct Answer: B
Rationale: The correct answer is B. The nurse should inform the client that their oncologist might prescribe a cold cap during treatment to reduce chemotherapy-induced hair loss by cooling the scalp. Choice A is incorrect as washing the hair during treatment is generally recommended. Choice C is incorrect as sunscreen is not typically needed for the scalp in this context. Choice D is incorrect as regrowth of hair can vary among individuals and is not guaranteed within a specific timeframe.
How should a healthcare provider assess and manage a patient with anemia?
- A. Monitor hemoglobin levels and provide iron supplements
- B. Administer B12 injections
- C. Monitor for signs of infection and administer folic acid
- D. Administer oxygen therapy
Correct Answer: A
Rationale: Corrected Question: To assess and manage a patient with anemia, monitoring hemoglobin levels and providing iron supplements are crucial. Anemia is commonly caused by iron deficiency, making iron supplementation a cornerstone of treatment. B12 injections (Choice B) are more relevant for treating megaloblastic anemia, not the typical iron-deficiency anemia. Monitoring for signs of infection and administering folic acid (Choice C) are important in specific types of anemia like megaloblastic anemia, but not the first-line approach for anemia management. Administering oxygen therapy (Choice D) is not the primary intervention for anemia unless severe hypoxemia is present, which is not typically seen in anemia.