Nokea
A nurse on a mental health unit is caring for a client who is in restraints. Which of the following actions should the nurse take?
- A. Release the client's restraints every 4 hr.
- B. Check the client's status every hour.
- C. Obtain written consent by the client for the placement of the restraints.
- D. Document the client's behavior leading to the initiation of the restraints.
Correct Answer: D
Rationale: Documenting behavior justifies restraint use and meets legal standards.
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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.
The client delivered a newborn by cesarean birth 1 day ago.
A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?
- A. You can apply counterpressure to your back with each position change.
- B. You should change positions as little as possible.
- C. You can splint the incision with a pillow when changing positions.
- D. You should use patterned-paced breathing when changing positions.
Correct Answer: C
Rationale: Splinting the incision with a pillow reduces pain during movement.
A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?
- A. Offer the client several choices at mealtimes.
- B. Alternate daily caregivers.
- C. Avoid discussing the client's fears.
- D. Remind the client of the day and time often.
Correct Answer: D
Rationale: Frequent orientation to time reduces confusion in delirium.
The nurse notes that the skin around the catheter's insertion site is edematous and cool.
A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?
- A. Document the infiltration
- B. Apply a warm compress
- C. Elevate the arm
- D. Stop the infusion
Correct Answer: D
Rationale: Stopping the infusion prevents further fluid extravasation.
The client has pyelonephritis and is receiving gentamicin via IV infusion.
A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?
- A. New onset of hearing loss
- B. Slurred speech
- C. Constipation
- D. Hypotension
Correct Answer: A
Rationale: Gentamicin can cause ototoxicity, leading to hearing loss.