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A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care?
- A. Restrain the client as soon as seizure activity begins.
- B. Keep the lights on when the client is sleeping.
- C. Keep the client's bed in the lowest position.
- D. Have a padded tongue depressor available at the bedside.
Correct Answer: C
Rationale: The correct answer is C: Keep the client's bed in the lowest position. This is important for client safety during a seizure as it reduces the risk of injury from falling out of bed. Keeping the bed low ensures a shorter fall distance and minimizes the impact. Restraint (choice A) is not recommended as it can lead to further injury during a seizure. Keeping lights on (choice B) can trigger seizures in some individuals. Having a padded tongue depressor available (choice D) is not relevant to seizure precautions.
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A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
- A. Count the apical pulsations for a full minute.
- B. Check the apical pulse with a Doppler device.
- C. Use the diaphragm of the stethoscope to listen to the apical pulsations.
- D. Press the stethoscope firmly against the client's skin.
Correct Answer: A
Rationale: The correct answer is A: Count the apical pulsations for a full minute. This is because counting the apical pulse for a full minute provides the most accurate assessment of the client's heart rate. It allows for any irregularities or fluctuations in the pulse to be detected.
Choice B is incorrect as using a Doppler device is not necessary for routine assessment of the apical pulse. Choice C is incorrect as the bell of the stethoscope, not the diaphragm, should be used to listen to the apical pulsations for better sound transmission. Choice D is incorrect as pressing the stethoscope firmly against the client's skin can create artifact noise and interfere with accurate auscultation.
A nurse is developing a therapeutic relationship with a client. The nurse should perform which of the following actions during the working phase of a therapeutic relationship?
- A. Determine the reason the client sought care.
- B. Instruct the client about methods to achieve goals.
- C. Discuss the client's new skill sets.
- D. Review the client's demographic information.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client about methods to achieve goals. During the working phase of a therapeutic relationship, the nurse focuses on helping the client achieve their goals through guidance, education, and collaboration. Instructing the client about methods to achieve goals empowers them to actively participate in their care and progress towards wellness. This action promotes client autonomy and self-efficacy, key components of a therapeutic relationship.
Incorrect choices:
A: Determining the reason the client sought care is typically done in the initial phase of the relationship.
C: Discussing the client's new skill sets may be more appropriate in the termination phase where progress is reviewed.
D: Reviewing the client's demographic information is necessary but not a primary action during the working phase.
A nurse is evaluating the 24-hr I&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?
- A. Intake 2,500 mL, output 500 mL
- B. Intake 2,400 mL, output 2,500 mL
- C. Intake 1,200 mL, output 700 mL
- D. Intake 800 mL, output 2,100 mL
Correct Answer: B
Rationale: A fluid intake close to output indicates balance. Excess output or retention suggests dehydration or overload.
A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?
- A. Cracks in oral mucous membranes
- B. Poor skin turgor
- C. Tachycardia
- D. Excessive pulmonary secretions
Correct Answer: C
Rationale: Tachycardia can indicate oxygen toxicity. Other symptoms include confusion and restlessness. Pulmonary secretions are expected in pneumonia, not a sign of toxicity.
A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?
- A. After palpating the abdomen
- B. Prior to percussing the abdomen
- C. After checking for kidney tenderness
- D. Prior to inspecting the abdomen
Correct Answer: B
Rationale: The correct answer is B: Prior to percussing the abdomen. Auscultation of bowel sounds should be done before percussing as it helps to assess the presence and quality of bowel sounds without causing any interference from other assessment techniques. Palpation (choice A) can stimulate bowel sounds, leading to inaccurate assessment. Checking for kidney tenderness (choice C) and inspecting the abdomen (choice D) are unrelated to auscultating bowel sounds.