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A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
- A. Check the client for injuries.
- B. Move hazardous objects away from the client.
- C. Notify the provider.
- D. Ask the client to describe how she felt prior to the fall.
Correct Answer: A
Rationale: The correct action is A: Check the client for injuries. This is the first priority to ensure the client's immediate safety and well-being. By assessing for injuries first, the nurse can determine the severity of the situation and provide appropriate care. Moving hazardous objects (B) can wait until the client's safety is ensured. Notifying the provider (C) can be done after assessing the client's condition. Asking the client to describe how she felt prior to the fall (D) is important but not as urgent as checking for injuries.
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A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?
- A. During the admission process.
- B. As soon as the client's condition is stable.
- C. During the initial team conference.
- D. After consulting with the client's family.
Correct Answer: A
Rationale: Correct Answer: A. During the admission process.
Rationale: Discharge planning should start early to ensure a smooth transition. During admission, the nurse can assess the client's needs, resources, and support system. This allows time to address any potential barriers to discharge and create a comprehensive plan. Starting discharge planning later may lead to delays and inadequate preparation for the client's transition. Initiating discharge planning during the admission process promotes continuity of care and helps prevent readmissions.
Summary of Other Choices:
B: Waiting until the client's condition is stable may delay discharge planning and increase the risk of complications during the transition.
C: Waiting for the initial team conference may result in missed opportunities to address discharge needs promptly.
D: Involving the client's family is important, but discharge planning should start early to ensure all aspects of the plan are considered and implemented effectively.
A nurse is talking with an older adult client who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I'm not sure I want to retire.' Which of the following responses should the nurse make?
- A. You would have so much more time to spend with your family.'
- B. You should consider getting a part-time job or doing volunteer work.'
- C. Let's talk about how the change in your job status will affect you.'
- D. Why wouldn't you want to retire and relax?
Correct Answer: C
Rationale: The correct response is C: "Let's talk about how the change in your job status will affect you." This response shows empathy and understanding towards the client's concerns and opens up a dialogue to explore the client's feelings and thoughts about retirement. It allows the nurse to assess the client's emotional readiness and concerns, facilitating a supportive conversation.
Other choices are incorrect:
A: This response assumes that the client's main concern is spending time with family, which may not be the case.
B: While volunteering or working part-time are valid options, this response does not address the client's current feelings and may come across as dismissive.
D: This response is judgmental and does not acknowledge the client's perspective or concerns, potentially shutting down communication.
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, 'What would happen if I arrived at the emergency department and I had difficulty breathing?' Which of the following responses should the nurse make?
- A. We would consult the person appointed by your health care proxy to make decisions.
- B. We would give you oxygen through a tube in your nose.
- C. You would be unable to change your previous wishes about your care.
- D. We would insert a breathing tube while we evaluate your condition.
Correct Answer: A
Rationale: The correct answer is A: We would consult the person appointed by your health care proxy to make decisions. This response aligns with the client's living will and respects their wishes for declining resuscitation. By involving the designated health care proxy, the healthcare team ensures that decisions are made in accordance with the client's preferences.
Choice B is incorrect because providing oxygen through a tube does not address the client's concerns about declining resuscitation. Choice C is incorrect as it does not address the client's current situation or need for support in the emergency department. Choice D is incorrect as it goes against the client's expressed wishes in the living will. It is important to prioritize the client's autonomy and respect their decisions regarding end-of-life care.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Pad the client's wrist before applying the restraints.
- B. Evaluate the client's circulation every 8 hr after application.
- C. Remove the restraints every 4 hr to evaluate the client's status.
- D. Secure the restraint ties to the bed's side rails.
Correct Answer: A
Rationale: The correct answer is A: Pad the client's wrist before applying the restraints. This is important to prevent pressure injuries and ensure the client's comfort and safety. Padding helps distribute pressure and reduces the risk of skin breakdown. Choices B, C, and D are incorrect. B is not recommended as it is essential to monitor circulation frequently, not just every 8 hours. C is incorrect because restraints should not be removed without a valid reason due to the risk of injury or harm to the client. D is also wrong as restraints should be secured to parts of the bed frame, not side rails, to prevent the client from using them to injure themselves or others.
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
- A. Assist the client into a prone position.
- B. Place a sleeve over the top of each leg with the opening at the knee.
- C. Make sure two fingers can fit under the sleeves.
- D. Set the ankle pressure at 65 mm Hg.
Correct Answer: C
Rationale: The correct answer is C: Make sure two fingers can fit under the sleeves. This action ensures proper fit and compression without causing restriction or compromising circulation. A: Assisting the client into a prone position is not necessary for applying the sleeves. B: Placing the sleeve with the opening at the knee is incorrect as it should be at the top of the leg. D: Setting the ankle pressure at 65 mm Hg is not specified for thigh-length sleeves and may not be appropriate.