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. Placing the restraint across the client's chest
- B. Applying the restraint over the client's gown
- C. Using a quick-release tie to secure the restraint
- D. Tying the restraint to the bed frame
Correct Answer: A
Rationale: Placing the restraint across the chest restricts breathing; it should be at the waist.
You may also like to solve these questions
A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
- A. Don't worry. Everything will work out for you.
- B. Your quality of life will be compromised if you make this decision.
- C. We should talk about your decision later.
- D. How will you discuss this decision with your loved ones?
Correct Answer: D
Rationale: This response supports the client's autonomy and encourages communication.
A nurse is reinforcing a teaching plan regarding proper lifting with a client. Which of the following strategies should the nurse include to prevent back injury when lifting an object?
- A. Hold object away from the body.
- B. Tighten the abdominal muscles.
- C. Bend at the waist.
- D. Keep legs straight.
Correct Answer: B
Rationale: Tightening abdominal muscles stabilizes the spine during lifting.
A nurse is assisting with developing a plan of care for a client.
Exhibit 1
Nurses' Notes
2 days ago:
Client admitted to telemetry unit for uncontrolled atrial fibrillation. Admission skin assessment, area of intact, blanchable skin on client's coccyx.
Today, 0900:
Wound on client's coccyx no longer covered with intact skin. Wound involves full-thickness skin loss, shallow depth with no tunneling. New granulation noted. Minimal amount of exudate noted. Client reports wound pain as 5 on a scale of 0 to 10 and is unable to find a comfortable position.
Complete the following sentence by using the lists of options. The nurse understands that which of the following dressing should be added to the plan of care
- A. hydrocolloid
- B. dry gauze
- C. hydrogel
- D. alginate
- E. transparent
Correct Answer: A
Rationale: Hydrocolloid dressings promote healing in full-thickness wounds with minimal exudate.
A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?
- A. Aren't you interested in learning how to perform this test?
- B. Let's talk about what you're thinking.
- C. I'll discuss this with your partner instead.
- D. Is this something you think you can do?
Correct Answer: B
Rationale: Exploring the client's thoughts addresses distractions and improves teaching effectiveness.
A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?
- A. Provide the client with three large meals eachSigma day.
- B. Limit snacks between meals.
- C. Provide the client with finger foods for meals.
- D. Restrict visitors during meals.
Correct Answer: C
Rationale: Finger foods simplify eating for clients with dementia, increasing intake.