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A nurse is preparing to obtain a health history from a client who is on bedrest. Which of the following positions should the nurse take to place the client at ease?
- A. Sit in a chair next to the bed.
- B. Stand at the side of the bed.
- C. Sit on the bed next to the client.
- D. Stand at the foot of the bed.
Correct Answer: A
Rationale: The correct answer is A: Sit in a chair next to the bed. This position allows the nurse to be at eye level with the client, promoting a sense of equality and comfort. Sitting next to the client also creates a more intimate and open environment for communication. Standing at the side or foot of the bed may make the client feel intimidated or uncomfortable. Sitting on the bed with the client can invade personal space and may not be professional. In summary, sitting in a chair next to the bed is the most appropriate position for the nurse to establish a therapeutic and trusting relationship with the client on bedrest.
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A nurse is performing postmortem care for a recently deceased client prior to the client's family viewing. Which of the following actions should the nurse take?
- A. Cross the client's arms across their chest.
- B. Hold the client's eyes shut for a few seconds.
- C. Place the client in a high-Fowler's position.
- D. Remove the client's dentures from their mouth.
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is appropriate because it helps create a peaceful appearance for the deceased client, providing a more dignified and comforting view for the family during the viewing. Holding the eyes shut is a common practice to maintain a natural appearance and show respect for the deceased.
Crossing the client's arms (Choice A) is not necessary and may not be culturally appropriate for all families. Placing the client in a high-Fowler's position (Choice C) is not recommended as it may not be comfortable or appropriate for viewing. Removing the client's dentures (Choice D) is also unnecessary and may not be respectful to the deceased.
The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
Correct Answer: B
Rationale: The correct answer is B: Place a container for soiled linens inside the client's room. This intervention is important to prevent the spread of infection. Placing a container for soiled linens inside the client's room ensures that contaminated linens are contained and not mixed with other linens, reducing the risk of transmitting the infection to others.
Rationale for why other choices are incorrect:
A: Wearing an N95 mask is not necessary unless the client has airborne precautions, such as tuberculosis.
C: Placing the client in a negative airflow room is typically reserved for clients with airborne infections to prevent the spread of droplet nuclei in the air.
D: Removing the mask after exiting the client's room is incorrect as the mask should be removed before exiting to prevent contamination outside the room.
In summary, choice B is correct as it directly addresses infection control measures related to soiled linens, while the other choices are not relevant to isolation precautions or are incorrect based on standard
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.
The nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe?
- A. Limit alcohol intake to two drinks per day.
- B. Keep daily fat intake to less than 35%.
- C. Administer an antibiotic medication.
- D. Place on 2,300 mg sodium diet.
- E. Administer an antihypertensive medication.
- F. Limit foods high in potassium.
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. A - Limiting alcohol intake reduces the risk of adverse health effects. D - A 2,300 mg sodium diet is beneficial for managing blood pressure. E - Antihypertensive medication helps control high blood pressure. B and F are not directly related to planning care for the client. C may not be necessary unless there is an infection present.
A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client, 'If you don't eat, I'll put restraints on your wrists and feed you.' The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
- A. Battery
- B. Assault
- C. Negligence
- D. Malpractice
Correct Answer: B
Rationale: The correct answer is B: Assault. Assault is the threat of harmful or offensive contact without the actual contact occurring. In this scenario, the AP's statement of putting restraints on the client and force-feeding them constitutes a threat of harm, which is considered assault. This is inappropriate behavior and violates the client's autonomy. Battery (choice A) involves actual harmful or offensive contact, which is not present in this situation. Negligence (choice C) refers to a failure to exercise reasonable care, which is not applicable here. Malpractice (choice D) involves professional negligence or misconduct, which is also not relevant in this context.