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A nurse is planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hr ago. Which of the following actions should the nurse include in the plan?
- A. Encourage the client to apply a heating pad for 2 hr at a time.
- B. Instruct the client to take deep, rhythmic breaths.
- C. Apply an ice pack to the client's back for 1 hr.
- D. Remove distractions from the client's room.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to take deep, rhythmic breaths. Deep breathing helps promote relaxation, reduces muscle tension, and distracts the client from pain sensations. This can be an effective nonpharmacological pain relief method.
A: Encouraging the client to apply a heating pad for 2 hours at a time may exacerbate the pain if it's already mild.
C: Applying an ice pack for 1 hour may not be suitable for mild back pain as it is more effective for acute injuries.
D: Removing distractions may help, but it does not directly address the client's pain.
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A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
- A. Change the PN infusion bag every 48 hr.
- B. Obtain a random blood glucose daily.
- C. Prepare the client for a central venous line.
- D. Administer the PN and fat emulsion separately.
Correct Answer: C
Rationale: The correct answer is C: Prepare the client for a central venous line. Parenteral nutrition (PN) with high dextrose concentrations can cause phlebitis and tissue damage if administered through a peripheral IV line. Therefore, a central venous line is appropriate for administering PN to prevent complications. Changing the PN bag every 48 hours (A) is important for infection control but not directly related to the administration method. Obtaining a random blood glucose daily (B) is important for monitoring glucose levels but does not address the administration method. Administering the PN and fat emulsion separately (D) is not necessary as they can be mixed in the same solution.
A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse's signature on the form confirms which of the following requirements? (Select all that apply.)
- A. The client speaks the same language as the nurse.
- B. The client has legal authority to do so.
- C. The client does not have a mental health condition.
- D. The client signed in the nurse's presence.
- E. The client was not coerced.
Correct Answer: B,D,E
Rationale: The correct answers are B, D, and E. B is essential as the client must have legal authority to give informed consent. D is crucial as the client's signature in the nurse's presence ensures authenticity. E is important to confirm that the client was not coerced. Choice A is incorrect as language proficiency does not determine consent validity. Choice C is incorrect as having a mental health condition does not automatically invalidate consent.
A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include?
- A. Change the dressing four times per day.
- B. Apply tincture of benzoin prior to removing the dressing.
- C. Use sterile gloves when removing the old dressing.
- D. Clean from the incision to the surrounding skin.
Correct Answer: C
Rationale: The correct answer is C: Use sterile gloves when removing the old dressing. This is important to prevent introducing infection to the incision site. Sterile gloves help maintain asepsis during the dressing change, reducing the risk of contamination. Changing the dressing four times per day (A) may disrupt the wound healing process by removing necessary protective barriers. Applying tincture of benzoin (B) can cause skin irritation and is unnecessary for routine dressing changes. Cleaning from the incision to the surrounding skin (D) can introduce microorganisms from the surrounding skin to the incision site, increasing infection risk.
A nurse is teaching a class about the guidelines for the standards of care for nursing. Which of the following defines the nursing scope of practice?
- A. The JEN Consultant
- B. Podcast League for Nursing
- C. Postnote ID # of Rights
- D. State Nurse Practice Acts
Correct Answer: D
Rationale: The correct answer is D: State Nurse Practice Acts. State Nurse Practice Acts define the legal scope of practice for nurses in each state, outlining what tasks and responsibilities nurses can perform. These acts help ensure patient safety and quality care by setting standards for nursing practice. Choice A, B, and C are unrelated to nursing scope of practice and do not provide any guidelines or regulations for nurses. Therefore, they are incorrect options.
A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using restraints, which of the following actions must the nurse take first?
- A. Obtain a prescription for restraints from the provider.
- B. Explain the procedure to the client and their family.
- C. Attempt less restrictive alternatives.
- D. Document the indications for using wrist restraints.
Correct Answer: C
Rationale: Correct Answer: C - Attempt less restrictive alternatives.
Rationale: Before resorting to using restraints, the nurse must first try less restrictive measures to ensure the safety and well-being of the client. This includes interventions such as redirecting the client's behavior, providing distractions, or addressing the underlying cause of the behavior. By attempting less restrictive alternatives, the nurse can promote the client's autonomy and prevent the potential negative effects of using restraints.
Summary:
A: Obtaining a prescription for restraints is important, but it should not be the first step.
B: Explaining the procedure to the client and their family is important but does not address the immediate need for less restrictive alternatives.
D: Documenting the indications for using wrist restraints is necessary but does not address the need to explore other options first.