Nokea
The client that the nurse is ambulating becomes dizzy and feels faint. Place the nurse's actions in the correct order to prevent the client from falling.
- A. Support and ease the client to the floor by sliding the client down the forward leg
- B. Call for help
- C. Bend at the knees and pull the client toward the forward leg
- D. Assess the client for injuries
- E. Protect the client's head from hitting objects on the floor
- F. Assume a broad stance with the stronger leg somewhat behind the other leg
Correct Answer: B,F,C,A,E,D
Rationale: The sequence ensures safety: call for help (B), establish a stable stance (F), lower the client safely (C, A), protect the head (E), and assess injuries (D).
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Clinic employees were taught to recognize the hazards of various chemicals using the National Fire Protection Association's (NFPA) diamond label and coding system. What should the nurse determine about the substance that has the label illustrated?
- A. It is extremely flammable.
- B. It can become explosive if mixed with water.
- C. It has no special hazard.
- D. It could cause a serious health injury.
Correct Answer: D
Rationale: The blue diamond with a 3 indicates a serious health hazard, capable of causing significant injury.
A client has been placed in isolation because he is diagnosed with a contagious illness. The nurse should be aware that:
- A. Linens from the client's bed should be double-bagged.
- B. Meals should be served on washable dishes.
- C. Extensive isolation rarely causes psychological problems.
- D. Paper trays and plastic utensils prevent disease transmission.
Correct Answer: A
Rationale: Linens should be double-bagged. Isolation refers to techniques used to prevent or to limit the spread of infection. Some form of isolation has been used for centuries, whether to protect a high-risk person from exposure to pathogens or to prevent the transmission of pathogens from an infected person to others. Special handling of articles and linen soiled by any body fluid is indicated. These articles should be placed in impervious bags before they are removed from the client's bedside. Bagging in watertight containers is indicated to prevent exposure of personnel and contamination of the environment. The outside of the bag should not be contaminated when placing articles inside it. Each hospital and community agency has procedures for labeling and decontaminating exposed articles. Items that are visibly soiled with body substances should be rinsed and placed in plastic bags or clearly marked containers, often labeled 'Contaminated.' If the outside of the bag becomes contaminated, placing that bag in another bag (double-bagging) is required.
The hospitalized client tells the nurse about feeling a strong shock when turning on an electric hair dryer. What should the nurse do first?
- A. Assess the client's heart rhythm and apical pulse
- B. Disconnect the hair dryer from the electrical outlet
- C. Assess the client's skin for signs of electrical burn
- D. Tag and send the hair dryer for inspection
Correct Answer: A
Rationale: Assessing the client's heart rhythm is the priority, as an electrical shock can cause dysrhythmias due to the body's conductivity.
The nurse is performing a physical examination of a 3 month-old with a suspected heart murmur. Which assessment should be performed first?
- A. Inspect the chest
- B. Auscultate the mass
- C. Percuss the mass
- D. Palpate the mass
Correct Answer: B
Rationale: Auscultate the mass. Auscultation of the chest to listen for a heart murmur is the first step in confirming the presence of a murmur and guides further assessment.
The nurse should perform which intervention when a client is restrained?
- A. Remove the restraints and provide skin care hourly.
- B. Document the condition of the client's skin every 3 hours.
- C. Assess the restraint every 30 minutes.
- D. Tie the restraint to the side rails.
Correct Answer: C
Rationale: The minimum standard is to visually assess the restraint every 30 minutes. Documentation is typically performed per a checklist or flow sheet. The ends of the restraint are tied to a part of the bed that allows for position changes without unfastening them.