Nokea
The client is being taught about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?
- A. Remove needle before discarding used syringes
- B. Wear gloves to dispose of the needle and syringe
- C. Don a face mask before administering the medication
- D. Wash hands before handling the needle and syringe
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The healthcare professional is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. What action should the healthcare professional take next?
- A. Document that the client responds to a painful stimulus.
- B. Observe the client's response to verbal stimulation.
- C. Place the client on seizure precautions for 24 hours.
- D. Report decorticate posturing to the healthcare provider.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
How should the nurse prepare the body of a deceased adult for transfer to the mortuary?
- A. Leave the body as is, no preparation needed
- B. Bathe the body and place ID tags on it
- C. Remove dentures before bathing the body
- D. Position the body with its head down and arms folded on its chest
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the healthcare provider take next?
- A. Raise the bed to a comfortable working level.
- B. Bend the client's knee.
- C. Move the knee toward the chest as far as it will go.
- D. Cradle the client's heel.
Correct Answer: D
Rationale: When providing passive ROM exercises to the hip and knee for an unconscious client, it is essential to support the joints of the knee and ankle. The next action should be to cradle the client's heel and gently move the limb in a slow, smooth, firm, but gentle manner. This helps maintain joint mobility and prevent contractures.
When a health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she 'can't handle' the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client's right to informed consent?
- A. The family cannot provide the consent required in this situation because the older adult is in a condition to make such decisions.
- B. Because the client is mentally incompetent, the son does not have the right to waive informed consent for her.
- C. The court will not allow the health care provider to make the decision to withhold informed consent under therapeutic privilege.
- D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.
Correct Answer: D
Rationale: In the scenario described, it is crucial for health care providers to obtain informed consent from the client before proceeding with any medical intervention. If informed consent is withheld and the treatment is carried out without the client's agreement, health care providers could be found guilty of negligence, specifically assault and battery. This legal principle emphasizes the importance of respecting a client's autonomy and right to make decisions about their own healthcare. Despite the son's wishes to withhold information from his mother, the client must be informed of the proposed treatment and given the opportunity to consent or refuse based on complete information provided by the healthcare team.
When measuring vital signs, the healthcare provider observes that a client is using accessory neck muscles during respirations. What follow-up action should the healthcare provider take first?
- A. Determine pulse pressure
- B. Auscultate heart sounds
- C. Measure oxygen saturation
- D. Check for neck vein distention
Correct Answer: C
Rationale: Observing a client using accessory neck muscles during respiration indicates respiratory distress. The priority action should be to measure oxygen saturation to assess the adequacy of oxygenation. This intervention provides crucial information about the client's respiratory status and helps guide further assessment and interventions.