Nokea
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?
- A. I can place an extension cord across my living room to plug in my television.
- B. I will hire someone to trim the tree that hangs low over the stairs of my front porch.
- C. I will place my alarm clock on my bedroom dresser across the room.
- D. I will replace the old throw rug in my kitchen with a new one.
Correct Answer: B
Rationale: Correct Answer: B - "I will hire someone to trim the tree that hangs low over the stairs of my front porch."
Rationale: This statement demonstrates understanding as it shows awareness of potential hazards (low-hanging tree) that could obstruct safe walker use. By hiring someone to trim the tree, the client is proactively ensuring a safe environment for mobility with the walker.
Summary of Incorrect Choices:
A: Placing an extension cord across the living room poses a tripping hazard, which is unsafe for walker use.
C: Placing the alarm clock on the bedroom dresser is unrelated to walker safety.
D: Replacing the throw rug in the kitchen is beneficial but not directly related to walker safety.
You may also like to solve these questions
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the client in a semi-lying position.
- B. Instill 15 mL of irrigation fluid into the catheter with each flush.
- C. Subtract the amount of irrigant used from the client's urine output.
- D. Perform the irrigation using a 20-mL syringe.
Correct Answer: C
Rationale: The correct answer is C: Subtract the amount of irrigant used from the client's urine output. This is the correct action because when using open irrigation technique, the nurse needs to account for the amount of irrigant introduced into the catheter to accurately assess the client's urine output. By subtracting the amount of irrigant used from the total output, the nurse ensures an accurate measurement of the client's urine output. This is crucial for monitoring the client's renal function and fluid balance.
Choice A is incorrect as the client should ideally be in a supine position during catheter irrigation to prevent spillage. Choice B is incorrect as the amount of irrigation fluid instilled should typically be equal to the amount of urine output, not a fixed amount. Choice D is incorrect as a 60-mL syringe is usually recommended for catheter irrigation to avoid excessive force and pressure on the catheter.
A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?
- A. Combine client care tasks when caring for multiple clients.
- B. Wait until the end of the shift to document client care.
- C. Use the planning step of the nursing process to prioritize client care delivery.
- D. Allow for interruptions in tasks to discuss client care issues with colleagues.
Correct Answer: C
Rationale: Correct Answer: C - Use the planning step of the nursing process to prioritize client care delivery.
Rationale:
1. The planning step involves setting goals, outcomes, and interventions, helping the nurse organize and prioritize care efficiently.
2. Prioritizing care based on client needs ensures critical tasks are addressed first, promoting client safety and well-being.
3. It allows the nurse to allocate time effectively, focusing on urgent and important tasks first.
4. By following the nursing process, the nurse can provide individualized care tailored to each client's specific needs.
Incorrect Choices:
A: Combining tasks can lead to overlooking important details for each client.
B: Waiting to document care can result in errors, omissions, and delays in communication.
D: Allowing interruptions can disrupt workflow and hinder efficient time management.
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
- A. Ask another nurse to observe the medication wastage.
- B. Notify the pharmacy when wasting the medication.
- C. Lock the remaining medication in the controlled substances cabinet.
- D. Dispose of the vial with the remaining medication in a sharps container.
Correct Answer: C
Rationale: The correct answer is C: Lock the remaining medication in the controlled substances cabinet. This is the correct action because opioids are controlled substances that require strict security measures to prevent diversion or misuse. By locking the remaining medication in the controlled substances cabinet, the nurse ensures that it is securely stored and accounted for.
Choice A: Asking another nurse to observe the medication wastage is unnecessary in this situation as the remaining medication should be properly secured rather than observed.
Choice B: Notifying the pharmacy when wasting the medication may be required for documentation purposes, but it does not address the immediate need to secure the remaining medication.
Choice D: Disposing of the vial with the remaining medication in a sharps container is incorrect as it does not follow proper protocol for handling controlled substances.
In summary, choice C is the correct action as it aligns with the necessary security measures for handling opioids, while the other choices do not address the specific requirements for controlled substances.
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
- A. Administer the medication with the needle at a 45° angle.
- B. Administer the medication to the client's non-dominant arm.
- C. Pull the client's skin layer downward at administration.
- D. Massage the injection site after administration.
Correct Answer: A
Rationale: The correct answer is A: Administer the medication with the needle at a 45° angle. Enoxaparin is a medication that is typically administered subcutaneously. Injecting at a 45° angle helps ensure proper absorption of the medication into the subcutaneous tissue, avoiding potential intramuscular injection. Administering to the non-dominant arm (B) or pulling the skin downward (C) are not necessary steps for administering enoxaparin. Massaging the injection site after administration (D) is contraindicated as it can increase the risk of bruising or bleeding.
A nurse is caring for a client who has pancreatitis. Select the 3 tasks the nurse should delegate to an assistive personnel (AP). First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia, Pulses to lower extremities weak with +2 dependent edema present, Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this am. States voiding without difficulty, clear yellow urine. Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle changes for heart failure. Provided medication teaching following provider's increase in furosemide dosage from.
- A. Document the client's vital signs.
- B. Measure the client's intake and output.
- C. Transfer the client from wheelchair to bed.
- D. Insert an NG tube for the client.
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Documenting vital signs is within the scope of practice for an assistive personnel (AP) as it involves measuring and recording objective data.
B: Measuring intake and output is a task that can be safely delegated to the AP as it requires basic monitoring skills and doesn't involve complex decision-making.
C: Transferring the client from a wheelchair to bed is a physical task that can be delegated to the AP, as long as proper body mechanics are used to prevent injury.
Summary:
D: Inserting an NG tube is a skilled nursing task that requires specialized training and should not be delegated to an AP.
E: No task provided for this option.
F: No task provided for this option.
G: No task provided for this option.