Nokea
An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take?
- A. Examine the elbow
- B. Administer pain medication
- C. Apply a warm compress to the elbow
- D. Assess the client's range of motion
Correct Answer: A
Rationale: The appropriate initial action for the nurse is to examine the elbow. This step is crucial to assess the site of pain, identify any visible signs of injury or inflammation, and determine the cause of the discomfort. Administering pain medication (Choice B) should come after a thorough assessment. Applying a warm compress (Choice C) might provide temporary relief but does not address the underlying cause. Assessing the client's range of motion (Choice D) is important but would come after the initial examination to further evaluate the elbow joint.
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How can self-injury be prevented when lifting a bedside cabinet?
- A. Standing close to the cabinet when lifting.
- B. Bending at the waist when lifting.
- C. Twisting while lifting to balance the load.
- D. Lifting with a quick motion.
Correct Answer: A
Rationale: The correct way to prevent self-injury when lifting a bedside cabinet is by standing close to the cabinet. By standing close, the individual can maintain better control and balance while lifting, reducing the risk of injury. Bending at the waist when lifting (choice B) can strain the back and lead to injury. Twisting while lifting (choice C) can also cause strain and imbalance. Lifting with a quick motion (choice D) can increase the risk of injury due to lack of control and improper body mechanics.
A client with a diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Compromised host precautions
Correct Answer: C
Rationale: Contact precautions are necessary when performing postmortem care on a client with MRSA to prevent the spread of infection. Contact precautions involve using barriers like gloves and gowns to limit direct contact with the deceased individual's body fluids and tissues. Airborne precautions are used for pathogens that are transmitted through the air, like tuberculosis. Droplet precautions are for pathogens that are transmitted through respiratory droplets, such as influenza. Compromised host precautions are not a recognized standard precaution type and are not applicable in this scenario.
A nurse is collecting data from a client who is reporting pain despite taking analgesics. Which of the following actions should the nurse take to determine the intensity of the client's pain?
- A. Ask the client what precipitates the pain.
- B. Question the client about the location of the pain.
- C. Offer the client a pain scale to measure their pain.
- D. Use open-ended questions to identify the client's pain sensations.
Correct Answer: C
Rationale: Offering the client a pain scale is the most appropriate action to determine the intensity of the client's pain. Pain scales help quantify the intensity of pain, providing a standardized way to assess and compare pain levels. Asking about precipitating factors (choice A) may help identify triggers but does not directly measure pain intensity. Questioning about the location of pain (choice B) helps with localization but not with quantifying intensity. Using open-ended questions (choice D) may provide insights into the quality and experience of pain but does not provide a standardized measure of intensity.
The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the nurse implement first?
- A. Check the drainage tubing for a kink
- B. Review the intake and output record
- C. Notify the healthcare provider
- D. Give the client 8 oz of water to drink
Correct Answer: A
Rationale: The correct answer is to check the drainage tubing for a kink. A kink in the tubing can obstruct urine flow, potentially causing the low output. By addressing this first, the nurse can ensure that there are no physical obstructions hindering urine drainage. Reviewing the intake and output record is important, but addressing a possible kink in the tubing takes precedence as it directly affects urine flow. Notifying the healthcare provider should be considered after assessing and resolving immediate issues. Giving the client water to drink may be appropriate, but addressing a kink in the tubing is the priority to ensure proper function of the urinary catheter.
A healthcare professional reviewing a client's health record notes a new prescription for lisinopril 10 mg PO once daily. The healthcare professional should identify this as which of the following types of prescription?
- A. Single
- B. Stat
- C. Routine
- D. Now
Correct Answer: C
Rationale: A prescription for once-daily medication is considered routine as it is meant for regular, daily administration to maintain therapeutic levels in the body. Single prescriptions are for one-time use only. Stat prescriptions are for immediate administration in urgent situations, while now prescriptions are also for immediate use but may have varying levels of urgency depending on the patient's condition. In this case, since the prescription is for once daily use, it falls under the category of routine prescription.