Nokea
The client is brought to the emergency department in handcuffs by the police. Witnesses said that the client became violent and confused after consuming large amounts of alcohol at a party. The client is placed in 4-point restraints, and ziprasidone hydrochloride is administered. The client is sleeping 30 minutes later. What is a priority action for the nurse at this time?
- A. Check for a history of bipolar disease
- B. Determine if restraints can now be removed
- C. Monitor for ECG changes
- D. Obtain blood for the current blood alcohol level
Correct Answer: B
Rationale: The client is now sleeping, suggesting reduced agitation. Determining if restraints can be removed (B) is the priority to minimize harm and promote safety. Bipolar history (A), ECG changes (C), and blood alcohol level (D) are important but less urgent.
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The nurse is reinforcing home care instructions to a client newly diagnosed with osteomalacia. Which of the following client statements indicate proper understanding of teaching? Select all that apply.
- A. I will avoid foods high in calcium and phosphorus.'
- B. I will avoid going outside on sunny days.'
- C. I will eat foods that are fortified with vitamin D.'
- D. I will engage in physical activity to increase bone strength.'
- E. I will use a cane to help me get around better.'
Correct Answer: C, D
Rationale: Vitamin D-rich foods (C) and physical activity (D) improve bone health in osteomalacia. Avoiding calcium/phosphorus (A), sunlight (B), or using a cane (E) are incorrect or unnecessary.
During the shift report, the night charge nurse tells the day charge nurse that the night unlicensed assistive personnel (UAP) is totally incompetent. What is the best response for the day charge nurse to give?
- A. Encourage the night nurse to provide the UAP with additional training
- B. Indicate that it is the night nurse's job to deal with staff problems
- C. Remind the night nurse that the UAP is doing the best job the UAP can
- D. Suggest that the night nurse discuss concerns with the nurse manager
Correct Answer: D
Rationale: Suggesting discussion with the nurse manager (D) addresses the issue professionally. Encouraging training (A), deflecting responsibility (B), or defending the UAP (C) are less appropriate.
A client who received complete thickness burns at 7:30 a.m. was rushed to the emergency room where IV therapy with Lactated Ringer's was begun. He is to receive $8,000 \mathrm{~mL}$ of solution in 24 hours. According to the Parkland formula, how much solution should he receive by 11:30 p.m.?
- A. 4,000 mL
- B. 5,000 mL
- C. 6,000 mL
- D. 7,000 mL
Correct Answer: C
Rationale: The Parkland formula states half the total fluid (4,000 mL) is given in the first 8 hours (by 3:30 p.m.), and the remaining 4,000 mL over the next 16 hours. By 11:30 p.m. (16 hours post-burn), the client should have received 6,000 mL.
The nurse is caring for a frail elderly client in her home. Which behavior, if observed or reported, should the nurse report to the supervisor for further evaluation of possible abuse?
- A. The client's daughter is attempting to be declared her mother's legal guardian.
- B. The client is frequently left in bed alone in the house for several hours at a time.
- C. The client has brown spots on her arms.
- D. The client says, 'My daughter doesn't like me very much. She yells at me.'
Correct Answer: B
Rationale: Leaving a frail client alone for hours poses neglect risk, warranting abuse evaluation. Guardianship, brown spots, or yelling are less definitive without context.
The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply.
- A. Date of birth
- B. First and last name
- C. Health care provider
- D. Medical record number
- E. Room number
Correct Answer: A, B, D
Rationale: Date of birth (A), first and last name (B), and medical record number (D) are reliable identifiers. Health care provider (C) and room number (E) are not specific to the client.