Nokea
A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?
- A. Using a quick-release tie to secure the restraint.
- B. Tying the restraint to the bed frame.
- C. Placing the restraint across the client's chest.
- D. Applying the restraint over the client's gown.
Correct Answer: C
Rationale: Placing the restraint across the chest restricts breathing and is unsafe, requiring intervention.
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A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?
- A. Hyperactive bowel sounds are present.
- B. Stomach contents are yellowish green in color.
- C. Aspirated stomach contents' pH measures 6.5.
- D. Residual volume of stomach contents measures 90 mL.
Correct Answer: C
Rationale: A pH of 6.5 suggests possible tube misplacement, requiring immediate reporting.
A nurse is assisting in the care of a client who has pneumonia in the medical unit. Which of the following information should the nurse include in discharge teaching for the client? (Select all that apply)
- A. Take antibiotics for 10 days.
- B. Ensure the oxygen delivery system is at least 8 feet from any heat source.
- C. Decrease the steroid dose each day.
- D. Take antibiotic medication with or without food.
- E. Adjust the oxygen flow rate as needed to ease breathing.
- F. Take steroid medication in the morning.
Correct Answer: A,B,D,F
Rationale: A: Ensures full treatment course. B: Reduces fire hazard. D: Flexibility aids compliance. F: Morning dosing minimizes sleep disruption.
A nurse is reinforcing teaching with an older adult client about the aging process. The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)
- A. Increased peripheral circulation.
- B. Increased constipation.
- C. Decreased muscle mass.
- D. Decreased cough reflex.
Correct Answer: B,C,D
Rationale: B: Reduced motility causes constipation. C: Sarcopenia reduces muscle mass. D: Weaker cough reflex increases aspiration risk.
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)
- A. A client receives burns from a heating pad.
- B. A client reports being dissatisfied with the temperature of the meals provided.
- C. A client becomes disoriented and falls out of bed.
- D. A client’s visitor becomes dizzy and faints in the client's room.
- E. A client is unable to afford the physical therapy that the provider recommends.
Correct Answer: A,C,D
Rationale: A: Injury requires reporting. C: Fall indicates safety issue. D: Visitor incident needs documentation.
A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?
- A. Use a catheter securing device to hold the catheter in place.
- B. Obtain urine from the drainage bag if a urinary specimen is required.
- C. Change the catheter bag every 3 days and as needed.
- D. Position the drainage bag higher than the client's bladder.
Correct Answer: A
Rationale: Securing the catheter prevents movement and reduces infection risk.