Nokea
Padding on a restraint helps:
- A. with pressure distribution so that bony prominences do not receive pressure when a client pulls against the restraints.
- B. the client feel more secure.
- C. to keep infection and wounds down.
- D. to keep restraints in place.
Correct Answer: A
Rationale: Padding distributes pressure so that bony prominences do not receive the brunt of pressure when a client pulls against the restraints. Pressure, especially over bony prominences, causes tissue damage due to ischemia.
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When entering the client's room, the nurse sees that the client is standing on the far side of the room with clothing on fire. Which action should be taken by the nurse immediately?
- A. Go find the nearest fire alarm box
- B. Grab a blanket to smother the fire
- C. Obtain water to douse the clothes
- D. Tell the client to drop and roll on the floor
Correct Answer: D
Rationale: Instructing the client to drop and roll immediately smothers the flames, addressing the fire on the client's clothing most effectively.
When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in?
- A. Competitive board games with older children
- B. Playing with their own toys along side with other children
- C. Playing alone with hand held computer games
- D. Playing cooperatively with other preschoolers
Correct Answer: D
Rationale: Playing cooperatively with other preschoolers. Cooperative play is typical of the late preschool period.
When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because
- A. normal patterns of behavior may be labeled as deviant, immoral, or insane
- B. the meaning of the client's behavior can be derived from conventional wisdom
- C. personal values will guide the interaction between persons from 2 cultures
- D. the nurse should rely on her knowledge of different developmental mental stages
Correct Answer: A
Rationale: Normal patterns of behavior may be labeled as deviant, immoral, or insane. Culture is an important variable in the assessment of individuals. To work effectively with clients, the nurse must be aware of a cultural distinctive qualities.
Which of these clients would the nurse recommend keeping in the hospital during an internal disaster at that facility?
- A. An adolescent diagnosed with sepsis 7 days ago and whose vital signs are maintained within low normal limits.
- B. A middle-aged woman known to have had an uncomplicated myocardial infarction 4 days ago
- C. An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis
- D. A young adult in the second day of treatment for an overdose of acetaminophen
Correct Answer: D
Rationale: A young adult in the second day of treatment for an overdose of acetaminophen. An overdose of Tylenol requires close observation for 3 to 4 days as well as Mucomyst PO during that time. A strong risk of liver failure exists immediately following Tylenol overdose.
Pressure is being exerted to the client's foot ulcer from the bottom bed guard, and the client needs to be pulled up in bed. The client weighs 130 lb. Which action by the nurse is best when no one is available to assist the nurse?
- A. Wait until sufficient help is available to pull up and reposition the client in bed
- B. Place pillows over the bed guard and elevate both of the client's legs on the pillows
- C. Place the bed in Trendelenburg position to relieve the pressure and then wait for help
- D. Use a slight Trendelenburg position, have the client lift the heels, and pull the client up in bed
Correct Answer: D
Rationale: Using a slight Trendelenburg position leverages gravity to assist in moving a lightweight client safely, while lifting the heels prevents friction injury. Waiting for help (A) delays relief, pillows (B) risk sliding, and full Trendelenburg (C) may compromise respiration.