Nokea
How often must physical restraints be released?
- A. every 2 hours
- B. between 1 and 3 hours
- C. every 30 minutes
- D. at least every 4 hours
Correct Answer: A
Rationale: Restraints must be released every 2 hours to assess circulation, skin integrity, and client comfort, with assessments every 30 minutes while restrained.
You may also like to solve these questions
Which of the following might be an appropriate nursing diagnosis for an epileptic client?
- A. Dysreflexia
- B. Risk for Injury
- C. Urinary Retention
- D. Unbalanced Nutrition
Correct Answer: B
Rationale: The epileptic client is at risk for injury due to the complications of seizure activity, such as possible head trauma associated with a fall. The other choices are not related to the question.
A nurse is caring for a retired MD. The MD asks the question, 'What type of cells create exocrine secretions?'
- A. alpha cells
- B. beta cells
- C. acinar cells
- D. plasma cells
Correct Answer: C
Rationale: Acinar cells create exocrine secretions.
A client is diagnosed with HIV. Which of the following are antiviral drug classes used in the treatment of HIV/AIDS?
- A. nucleoside reverse transcriptase inhibitors
- B. protease inhibitors
- C. HIV fusion inhibitors
- D. all of the above.
Correct Answer: D
Rationale: All of the choices are anti-HIV drugs.
A community health nurse is asked to organize a health promotion project that plans to provide glucose screening. This activity is most beneficial within what realm?
- A. Testing that is performed by volunteers at a local department store and is open to the public
- B. At a professional health fair activity available for selected persons who have been screened as being at risk
- C. Mass-marketing vouchers for free fingersticks at a local drug store, where the pharmacist makes recommendations on the findings
- D. Testing that is performed by a nurse professional, who immediately provides education regarding the findings
Correct Answer: B
Rationale: Glucose screening is most effective for high-risk or symptomatic individuals at a health fair, ensuring targeted and meaningful results.
The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions should be taken first?
- A. performing a physical assessment prior to administration
- B. obtaining the most recent lab values regarding renal function
- C. reviewing peaks and troughs for the past few days
- D. ensuring the client is not allergic to the medication
Correct Answer: D
Rationale: Even before the physical assessment (which might or might not be indicated at the time of administration of Vancomycin), ensuring that the client is not allergic to the medication is the most critical action the nurse must take before administering any drug. Lab values regarding renal functioning and therapeutic ranges via peaks and troughs are also important with some medications such as Vancomycin because renal damage can occur if blood drug levels remain high over time.