Nokea
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.
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While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications.
A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?
- A. Autonomy
- B. Justice
- C. Veracity
- D. Beneficence
Correct Answer: C
Rationale: Veracity reflects truthfulness, as the nurse honestly discusses medication adverse effects.
A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?
- A. You should only drink 2 cups of coffee per day.
- B. You should elevate the head of the bed while sleeping.
- C. You should eat three large meals and two snacks per day.
- D. You should lay down for 1 hour following a meal.
- E. None
- F. None
Correct Answer: B
Rationale: Elevating the head of the bed reduces acid reflux during sleep, a key GERD management strategy.
A nurse is reinforcing teaching with the guardian of a 2-month-old infant about immunizations. Which of the following statements by a guardian indicates an understanding of the teaching?
- A. My baby will receive three doses of the meningococcal immunization before kindergarten.
- B. I should not feed my baby anything for 2 hours prior to an immunization.
- C. I should expect my baby to have a high fever for 24 hours after an immunization.
- D. My baby will receive the rotavirus immunization orally.
Correct Answer: D
Rationale: Rotavirus vaccine is given orally, indicating understanding.
A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?
- A. Decreased blood pressure
- B. Decreased skin turgor
- C. Weight loss
- D. Crackles heard in the lungs
Correct Answer: D
Rationale: Crackles in the lungs indicate fluid overload from excessive enteral feeding.
A nurse is reviewing laboratory findings for three clients. Which of the following laboratory results should the nurse expect for a client who has pancreatitis?
- A. Elevated ammonia
- B. Elevated lipase
- C. Prolonged PT/INR
- D. Decreased albumin
Correct Answer: B
Rationale: Elevated lipase is a specific marker of pancreatitis.