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A nurse is working with a client in an extended care facility. Which bed position is preferred for a client, who is at risk for falls, as part of a prevention protocol?
- A. All 4 side rails up, wheels locked, bed closest to door
- B. Lower side rails up, bed facing doorway
- C. Knee-high, head slightly elevated, bed in lowest position
- D. Bed in lowest position, wheels locked, place bed against wall
Correct Answer: D
Rationale: Bed in lowest position, wheels locked, place bed against wall. Using all 4 side rails is considered a restraint and limits client autonomy unless medically necessary with an order. Lower side rails alone do not adequately prevent falls. The bed in the lowest position with wheels locked and placed against the wall minimizes fall risk while allowing the client freedom of movement.
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A client with pneumococcal pneumonia was started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul taste and smell to the client's sputum. Which one would alert the nurse to a complication?
- A. I have a sharp pain in my chest when I take a breath.'
- B. I have been coughing up foul-tasting, brown, thick sputum.'
- C. I have been sweating all day.'
- D. I feel hot off and on.'
Correct Answer: B
Rationale: Foul smelling and tasting sputum signals a risk of a lung abscess. This puts the client in grave danger since abscesses are often caused by anaerobic organisms. This client most likely would need a change of antibiotics. Sharp chest pain on inspiration called pleuritic pain is an expected finding with this type of pneumonia. The other options are expected in the initial 24 to 48 hours of therapy for infections.
The nurse and NA are caring for the client with hepatitis A. The nurse determines that the NA understands correct infectious precautions for this client when observing what action?
- A. Wears a mask, gown, and gloves when taking the client's vital signs
- B. Wears a gown and gloves when changing the client's incontinent briefs
- C. Wears gloves when providing urinary catheter and perineal care
- D. Wears a gown and gloves when asking the client about snack food options
Correct Answer: B
Rationale: B: Gown and gloves are required for contact precautions during incontinent brief changes due to fecal transmission risk. A: Masks are unnecessary as hepatitis A is not airborne. C: Gloves alone are insufficient; a gown is needed. D: PPE is not required for non-contact interactions.
The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the provider?
- A. nausea and vomiting
- B. fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
- C. diffuse macular rash
- D. muscle tenderness
Correct Answer: B
Rationale: fever of 103 degrees Fahrenheit (39.5 degrees Celsius). Persistent, prolonged fever may be an indication that the antibiotics are not effective and may need to be changed.
The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching?
- A. I use a sliding scale to adjust regular insulin to my sugar level.'
- B. Since my eyesight is so bad, I ask the nurse to fill several syringes.'
- C. I keep my regular insulin bottle in the refrigerator.'
- D. I always make sure to shake the NPH bottle hard to mix it well.'
Correct Answer: D
Rationale: I always make sure to shake the NPH bottle hard to mix it well.' The bottle should be rolled gently, not shaken.
The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
- A. Disconnect the client from the ventilator and use a manual resuscitation bag
- B. Perform a quick assessment of the client's condition
- C. Call the respiratory therapist for help
- D. Press the alarm re-set button on the ventilator
Correct Answer: B
Rationale: A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A quick assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then require using a manual resuscitation bag and calling the respiratory therapist.