Nokea
An older adult has become very confused after surgery for repair of a hip fracture. The client has repeatedly tried to climb over the bedrails and the nurse is considering placing the client in a Posey vest that is secured to the bed. Which of the following must the nurse consider when applying restraints to a client? Select all that apply.
- A. An alternate method should be tried prior to applying a restraint.
- B. Confused clients are almost always safer in restraints.
- C. Restraints must be removed and the client reassessed at least every 2 hours.
- D. A written policy for application of restraints must be in place.
- E. The most restrictive restraint should be applied.
- F. The nurse does not need an order for a restraint if the client is in danger.
Correct Answer: A,C,D
Rationale: Alternatives (A), reassessment every 2 hours (C), and a written policy (D) are required for restraints. Confused clients aren't always safer (B), most restrictive (E) is incorrect, and an order is needed (F).
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The nurse is assessing a client with suspected hyperthyroidism. Which of the following findings would the nurse expect?
- A. Weight gain and lethargy.
- B. Tremors and heat intolerance.
- C. Bradycardia and cool skin.
- D. Increased appetite and constipation.
Correct Answer: B
Rationale: tremors and heat intolerance are common symptoms of hyperthyroidism due to increased metabolic rate
The nurse is assessing a client at home who is receiving outpatient hemodialysis 12 hours a week. The nurse knows the client needs further instruction about proper diet when he states which of the following?
- A. I drink prune juice when I'm constipated.
- B. I drink ginger ale with lunch.
- C. I drink 1 cup of milk with my dinner.
- D. My bread choice is white rather than whole grain.
Correct Answer: C
Rationale: Milk is high in phosphorus and potassium, which should be limited in hemodialysis patients to prevent electrolyte imbalances.
When administering a capsule that is individually wrapped to a client, when should the wrapping be removed?
- A. When initially obtained from the medicine cart
- B. When placed in the medicine cup
- C. Prior to entering the client's room
- D. At bedside in the client's presence
Correct Answer: D
Rationale: Removing the wrapping at the bedside (D) ensures the client sees the medication, enhancing safety and trust.
A child was exposed to the hepatitis A virus, became ill, and made a full recovery 2 years ago. The child is now immune to the hepatitis A virus and will likely be protected for the rest of her life. This type of immunity is referred to as
- A. active artificial immunity.
- B. naturally acquired active immunity.
- C. artificially acquired passive immunity.
- D. naturally acquired passive immunity.
Correct Answer: B
Rationale: Recovery from hepatitis A infection confers lifelong immunity via naturally acquired active immunity, as the body produces its own antibodies.
The charge nurse considers both patient-related and staff-related factors when making daily assignments. All of the following are patient-related factors EXCEPT
- A. mechanical ventilation use.
- B. complex medication regimen.
- C. isolation precaution requirements.
- D. nurse-to-client ratio.
Correct Answer: D
Rationale: Nurse-to-client ratio is a staff-related factor, affecting workload distribution. Ventilation, medications, and isolation are patient-specific needs.