Nokea
A nurse is preparing for the admission of a client who has a seizure disorder. Which of the following supplies should the nurse place at the bedside for this client?
- A. NG tube
- B. Suction machine
- C. Syringe containing lorazepam
- D. Tongue blade
Correct Answer: B
Rationale: A suction machine clears airways during a seizure, enhancing safety.
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The partner of a client who is receiving hospice care.
A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for pain management. Which of the following statements by the partner indicates an understanding of the teaching?
- A. My husband won't need medication for breakthrough pain while using music therapy.
- B. I will discontinue music therapy when my husband is no longer responsive.
- C. Playing music will increase my husband's alertness.
- D. Music will distract my husband's awareness of the pain.
Correct Answer: D
Rationale: Music therapy distracts from pain perception, aiding management.
A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?
- A. Thoroughly explain each procedure to the toddler.
- B. Start the examination with routine immunizations.
- C. Allow the toddler to handle the equipment.
- D. Completely undress the toddler.
Correct Answer: C
Rationale: Allowing the toddler to handle equipment reduces fear and increases cooperation.
The client becomes combative and threatens other clients and staff.
A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?
- A. Stand in front of the client to block them from others in the room.
- B. Apply restraints according to the facility's standing order.
- C. Ensure there are enough staff members available for assistance.
- D. Obtain a PRN prescription for restraints from the provider.
Correct Answer: C
Rationale: Ensuring staff availability ensures safety without immediate restraint use.
A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?
- A. Sleep apnea
- B. Paresthesias
- C. Disorientation
- D. Tonic-clonic seizures
Correct Answer: C
Rationale: Disorientation is common shortly after ECT.
A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?
- A. Asking the client to point their toes before applying the stockings
- B. Ensuring that creases in the stockings are on the front of the client's legs
- C. Turning the stockings inside out before applying them
- D. Applying the stockings before the client gets out of bed
Correct Answer: B
Rationale: Creases should be avoided to prevent skin irritation; this requires intervention.