Nokea
During an admission assessment of an older adult client, a nurse should identify which of the following findings as a potential indication of abuse?
- A. Bruises on the arms in various stages of healing
- B. Recent weight gain
- C. Complaints of joint pain
- D. Frequent visits to different providers
Correct Answer: A
Rationale: Bruises on the arms in various stages of healing should be identified as a potential indication of abuse in an older adult. These bruises may suggest physical harm or neglect, which are concerning signs of abuse. Recent weight gain (Choice B) is not typically associated with abuse and can have various causes, such as dietary changes or health conditions. Complaints of joint pain (Choice C) are more likely related to musculoskeletal issues rather than abuse. Frequent visits to different providers (Choice D) could indicate seeking multiple opinions or healthcare needs and do not necessarily point to abuse.
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When admitting a client with an abdominal wound, which precaution should be taken?
- A. Contact precautions
- B. Droplet precautions
- C. Airborne precautions
- D. Standard precautions
Correct Answer: A
Rationale: When admitting a client with an abdominal wound, contact precautions should be implemented. Contact precautions are used to prevent the spread of infections that are spread by direct or indirect contact. In the case of abdominal wounds, bacteria and pathogens can easily be transmitted through contact with the wound or wound drainage. Droplet precautions are used for infections transmitted through respiratory droplets, such as influenza. Airborne precautions are used for infections spread through the air, like tuberculosis. Standard precautions are used for all clients to prevent the spread of infections and should be followed in addition to specific precautions based on the type of infection.
A client who is confused and pulling at the tubing of her IV is being cared for by a nurse. Which of the following actions should the nurse take before requesting a prescription for restraints from the provider?
- A. Place the client in a room away from the nurses' station.
- B. Limit the client's visitors.
- C. Give the client washcloths to fold.
- D. Close the door of the client's room.
Correct Answer: C
Rationale: Providing the client with washcloths to fold is a non-restrictive intervention that can help distract and engage the client, potentially reducing the need for restraints. This action promotes a therapeutic and calming environment for the confused client. Placing the client in a room away from the nurses' station (Choice A) may not address the underlying issue of confusion and agitation. Limiting the client's visitors (Choice B) may not directly assist in managing the client's behavior. Closing the door of the client's room (Choice D) does not actively engage the client in a therapeutic intervention to address the behavior.
The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique. Which technique will the healthcare team use for logrolling?
- A. Involve at least three to four people.
- B. Instruct the patient not to reach for the opposite side rail when turning.
- C. Move the bottom part of the patient's torso first and then the top part.
- D. Use pillows for support before turning.
Correct Answer: A
Rationale: The correct technique for logrolling involves at least three to four people to ensure the safety and proper alignment of the patient's spine. Logrolling requires coordinated effort from multiple individuals to prevent twisting or bending of the spine, hence option A is correct. Option B is incorrect as patients with spinal cord injuries should not be instructed to reach for the opposite side rail due to the risk of causing harm. Option C is incorrect as moving the bottom part of the patient's torso first could lead to spinal misalignment. Option D is incorrect as pillows should be used for support and comfort after the patient has been successfully turned, not before.
A healthcare professional is preparing to administer dextrose 5% in water (D5W) 1,000-mL IV to infuse over 10 hr. How many mL/hr should the IV infusion pump be set to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)
- A. 100 mL/hr
- B. 150 mL/hr
- C. 75 mL/hr
- D. 50 mL/hr
Correct Answer: A
Rationale: To infuse 1,000 mL over 10 hr, the IV pump should be set to deliver 100 mL/hr. This calculation is derived by dividing the total volume (1,000 mL) by the total time in hours (10 hr), resulting in the infusion rate of 100 mL/hr. Choices B, C, and D are incorrect as they do not accurately reflect the correct calculation for this scenario.
The client is preparing for discharge following treatment for heart failure. Which statement by the client indicates a need for further teaching?
- A. I will weigh myself every day at the same time.
- B. I will call my doctor if my legs swell more.
- C. I will take my water pill only when I feel short of breath.
- D. I will limit the amount of salt in my diet.
Correct Answer: C
Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to manage fluid retention. Option A is correct as daily weight monitoring helps track for fluid retention. Option B is correct as worsening leg swelling should prompt contacting the healthcare provider. Option D is correct as limiting salt intake is essential in managing heart failure. Therefore, option C is the statement that indicates a need for further teaching.