Nokea
The client with a left-sided weakness is to be discharged to home, where the client has an electrical bed. In preparation for discharge, the nurse assesses the client's ability to get out of bed independently- Which client actions indicate that further instruction is needed? Select all that apply.
- A. Places the bed in the lowest position
- B. Raises the head of the bed (HOB)
- C. Rolls onto the left side
- D. Pushes against the mattress with the weak elbow and stronger hand to rise to a sitting position
- E. Slides legs off the bed while pushing against the mattress to raise the body off the bed
- F. Once in a sitting position, sits at the edge of the bed for a few minutes before standing
Correct Answer: C,D
Rationale: C: Rolling onto the weaker left side is incorrect; the client should roll onto the stronger right side to maximize strength and stability. D: Using the weak elbow instead of the stronger elbow and hand to push off increases the risk of injury and instability.
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A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should first
- A. focus on reality orientation to place and person
- B. assist with the report of the client's complaint to the police
- C. obtain more details of the client's claim of abuse
- D. document the statement on the client's chart with a report to the manager
Correct Answer: C
Rationale: Obtain more details of the client's claim of abuse. The advocacy role of the professional nurse, as well as the legal duty of the reasonable prudent nurse, requires the investigation of claims of abuse to ensure appropriate action and protection for the client.
A power outage occurs at a hospital, and a backup generator supplying power to a telemetry unit fails. After obtaining a flashlight, what is the nurse's next best action?
- A. Call the nursing supervisor
- B. Assess the most critically ill clients
- C. Obtain oxygen tanks for clients on oxygen
- D. Delegate which clients the NA should monitor
Correct Answer: C
Rationale: Obtaining oxygen tanks is the priority, as room oxygen sources fail during a power outage, and clients on oxygen are at immediate risk.
The nurse is teaching the client with a latex allergy about home and personal safety. Which information should the nurse emphasize? Select all that apply.
- A. Remove items in the home made from synthetic materials.
- B. Keep emergency telephone numbers readily accessible.
- C. Have someone remove any latex balloons and rubber bands.
- D. Avoid foods such as kiwi, bananas, avocados, and chestnuts.
- E. Certain plants, such as poinsettia plants, help remove allergens.
Correct Answer: B,C,D
Rationale: B: Emergency numbers are critical for anaphylaxis. C: Latex items like balloons and rubber bands must be removed to avoid exposure. D: Certain foods can trigger cross-reactive allergic reactions. A and E are incorrect as synthetic materials are safe, and poinsettias can cause reactions.
A patient asks a nurse the following question. Exposure to TB can be identified best with which of the following procedures? Which of the following tests is the most definitive of TB?
- A. Chest x-ray
- B. Mantoux test
- C. Breath sounds examination
- D. Sputum culture for gram-negative bacteria
Correct Answer: B
Rationale: The Mantoux is the most accurate test to determine the presence of TB.
The nurse asks the NA to apply a mitten restraint for the client seated in the wheelchair next to the bed. Which observation by the nurse indicates that the NA needs further instructions on applying restraints?
- A. Restraint strap is tied to the bed frame next to the client.
- B. Restraint straps are secured using a half-bow slip knot.
- C. Two fingers can be inserted between the restraint and client's skin.
- D. Mesh portion of the mitten restraint is on the back of the hand.
Correct Answer: A
Rationale: Tying the restraint to the bed frame instead of the wheelchair frame risks injury if the wheelchair moves, indicating the NA needs further instruction.