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A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?
- A. Leave the television on in the client's room
- B. Raise all four side rails while the client is in bed.
- C. Move the overbed table away from the bed.
- D. Apply a motion sensor mat to the client's bed
Correct Answer: D
Rationale: A motion sensor mat alerts staff to movement, reducing fall risk in dementia clients. TV can agitate, four rails are a restraint, and moving the table doesn't directly prevent falls.
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A nurse is preparing to perform a blood glucose test. After performing hand hygiene and donning gloves, in which order should the nurse perform the following actions to obtain a capillary blood sample?
- A. Allow the site to dry.
- B. Pierce the puncture site quickly.
- C. Squeeze the site gently to obtain a blood droplet.
- D. Cleanse the site with an antiseptic swab.
- E. Apply blood to the test strip.
Correct Answer: D,A,B,C,E
Rationale: The order is: Cleanse with antiseptic (D), allow to dry (A), pierce (B), squeeze for blood (C), and apply to strip (E) for an accurate, sterile sample.
A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?
- A. Use a fire extinguisher at the source of the smoke.
- B. Close the doors to the room and to the bathroom.
- C. Activate the fire alarm system.
- D. Assist the client to a nearby common area.
Correct Answer: D
Rationale: Assisting the client to safety is the first priority in a fire emergency per the RACE protocol (Rescue, Alarm, Contain, Extinguish).
History and Physical
1000:
Client reports generalized weakness and increased fatigue over the past few months.
Client states they become short of breath after climbing a flight of stairs and are having difficulty keeping up with their grandchildren.
History of rheumatoid arthritis. Reports taking naproxen 500 mg twice a day.
Client reports they follow a vegan diet.
Denies pain or discomfort.
Bilateral breath sounds clear and present throughout.
Mucous membranes pale.
Apical pulse rapid, regular.
For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Prescription: Administer an iron supplement.
- A. Administer an iron supplement
- B. Collaborate with a nutritional consultant.
- C. Place the client on a low sodium diet.
- D. Restrict fluid Intake.
Correct Answer:
Rationale: Low Hct, Hgb, and ferritin indicate iron deficiency anemia, making iron supplementation anticipated.
A nurse is assisting in the plan of care for a client who has thrombocytopenia. Which of the following actions should the nurse include in the plan?
- A. Check the client for ecchymosis.
- B. Initiate protective isolation for the client.
- C. Administer ibuprofen for mild headache.
- D. Instruct the client to shave with a disposable razor.
Correct Answer: A
Rationale: Checking for ecchymosis (bruising) monitors for bleeding, a risk in thrombocytopenia due to low platelets. Isolation isn't needed, ibuprofen increases bleeding risk, and razors should be avoided.
A nurse is assisting in the care of the client who is postoperative following a fasciotomy. The nurse is reviewing the client's electronic medical record (EMR). Which of the following statements in the EMR indicate the client's condition is improving since implementing interventions?
- A. Client reports pain as a 4 on a scale of 0 to 10.
- B. Bilateral breath sounds clear and present throughout.
- C. Right leg warm to touch, incision dressing dry and intact.
- D. Wound drain negative-pressure system, draining small amount of serosanguinous fluid.
Correct Answer: C
Rationale: Fasciotomy relieves compartment syndrome pressure, so improvement hinges on limb perfusion and wound stability. Right leg warm to touch with a dry, intact dressing indicates good circulation and no excessive bleeding or infection key recovery signs post-fasciotomy. Pain at 4/10 may suggest improvement if previously higher, but it's subjective and less specific without baseline comparison. Clear breath sounds are reassuring but unrelated to the surgical site unless pulmonary complications were a concern, not implied here. Small serosanguinous drainage is normal initially, but small' alone doesn't confirm progress without prior volume context. Warmth and a stable dressing directly reflect surgical success restored blood flow and wound healing making it the strongest EMR indicator of improvement, per postoperative assessment priorities.