Nokea
A nurse is reviewing a client's electronic medical record (EMR). Which of the findings should the nurse identify as a risk factor for a potential accident or injury?
- A. History of dementia
- B. Steady gait
- C. History of gastric reflux
- D. Age of 45
Correct Answer: A
Rationale: Dementia increases confusion and fall risk, predisposing to accidents.
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A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder. As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, 'I am afraid of needles.' Which of the following actions should the nurse take?
- A. Request a change in the medication route to PO.
- B. Remind the client that they must receive the medication as prescribed.
- C. Tell the client not to worry because the pain will be temporary.
- D. Ask one of the client's loved ones to encourage them to receive the IM
Correct Answer: A
Rationale: Requesting a PO route addresses the client's fear while ensuring treatment continuity.
A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
- B. The sterile solution is poured with the bottle held over the field.
- C. Unnecessary sterile items are placed on the field.
- D. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
Correct Answer: B
Rationale: Pouring over the field risks contamination from the bottle.
A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- A. Administering vaginal cream to a client who has a vaginal infection
- B. Providing postmortem care for a client who has just died
- C. Suctioning a tracheostomy for a client who has a recent head injury
- D. Changing a peripheral IV dressing for a client who is postoperative
Correct Answer: B
Rationale: Postmortem care is within the AP's scope; medication administration and invasive procedures are not.
A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take?
- A. Play music in the client's room.
- B. Keep the client's room well lit.
- C. Ensure that the client's room is kept at a cool temperature.
- D. Encourage the client to abstain from distracting activities.
Correct Answer: A
Rationale: Music is a nonpharmacological method to distract from pain and promote relaxation.
A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Request a prescription renewal from the provider every 36 hr.
- B. Check the client's range of motion every 6 hr.
- C. Secure the restraints with a square knot.
- D. Make sure two fingers fit under the restraints.
Correct Answer: D
Rationale: Ensuring two fingers fit prevents excessive tightness and circulation issues.