Nokea
Before leaving the room, which of the following nursing access to the nurse's place, the client's place.
- A. The nurse straightens the client's linens.
- B. The nurse informs the client when leaving the room.
- C. The nurse offers to give the client a back rub.
- D. The nurse shares some current events with the client.
Correct Answer: B
Rationale: Informing the client when leaving reduces anxiety and enhances safety.
You may also like to solve these questions
The nurse has completed the teaching plan for the client diagnosed with psoriasis. Which statement indicates the need for further teaching?
- A. I will check my skin every day for redness with tenderness.'
- B. I must take my psoralen medication two (2) hours before my treatment.'
- C. I will wear dark glasses during my treatment and the rest of the day.'
- D. The coal-tar ointments and lotions will not stain my clothes.'
Correct Answer: D
Rationale: Coal-tar ointments stain clothes, indicating a need for further teaching. Daily skin checks, psoralen timing, and dark glasses are correct for PUVA therapy.
The nurse writes the problem 'impaired skin integrity' for a client with stage IV pressure ulcers. Which interventions should be included in the plan of care? Select all that apply.
- A. Turn the client every three (3) to four (4) hours.
- B. Ask the dietitian to consult.
- C. Have the client sign a consent for pictures of the wounds.
- D. Obtain an order for a low air-loss bed.
- E. Elevate the head of the bed at all times.
Correct Answer: B,C,D
Rationale: Dietitian consult, wound photos (with consent), and low air-loss bed address stage IV ulcers. Turning every 3–4 hours is too infrequent, and constant head elevation increases coccyx pressure.
The client has an entrance wound on the right hand and an exit wound on the left hand after contact with a high-power electrical line. Considering the nature and trajectory of the electrical current, which nursing action is priority?
- A. Obtain a 12-lead ECG
- B. Check pupil size and reaction
- C. Auscultate both lung fields
- D. Check arm range of motion
Correct Answer: A
Rationale: Electrical current will follow through the path of least resistance in the body, which is the bloodstream. The heart could have been damaged by the electrical current. Therefore, obtaining a 12-lead ECG is priority. Pupil checks or lung auscultation may be indicated but are not the priority. ROM is not a priority based on the ABCs of medical emergencies.
The paraplegic client is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital?
- A. Complete the Braden Scale.
- B. Monitor the client on a Glasgow Coma Scale.
- C. Assess for Babinski’s sign.
- D. Initiate a Brudzinski flow sheet.
Correct Answer: A
Rationale: The Braden Scale assesses pressure ulcer risk, guiding interventions. Glasgow, Babinski, and Brudzinski are neurological, not relevant to ulcers.
When planning the child's discharge, what nursing instruction is most appropriate for the nurse to provide the parent concerning the cotton ball in the client's ear canal?
- A. Leave the cotton ball in place until it is saturated.
- B. Keep the cotton ball placed loosely within the ear canal.
- C. Remove the cotton ball in peroxide before insertion.
- D. Remove the cotton ball when the cotton becomes dry.
Correct Answer: B
Rationale: A loosely placed cotton ball protects the ear without causing pressure.