Nokea
The nurse can best ensure the safety of a client suffering from dementia who wanders from the room by which action?
- A. Repeatedly remind the client of the time and location
- B. Explain the risks of walking with no purpose
- C. Use protective devices to keep the client in the bed or chair in the room
- D. Attach a wander-guard sensor band to the client's wrist
Correct Answer: D
Rationale: This type of identification band easily tracks the client's movements and ensures safety while the client wanders on the unit. Restriction of activity is inappropriate for any client unless they are potentially harmful to themselves or others.
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A client diagnosed with acute glomerulonephritis has pitting edema in the lower extremities, a blood pressure of 170/80 mm Hg, and proteinuria. When the practical nurse is assisting in the development of a care plan for this client, which measurement is the most accurate indicator of fluid loss or gain and should therefore be included in the plan?
- A. Blood pressure measurements
- B. Daily weight measurements
- C. Severity of pitting edema
- D. Strict intake and output measurements
Correct Answer: B
Rationale: Daily weights (B) are the most accurate for tracking fluid balance in glomerulonephritis. Blood pressure (A), edema (C), and intake/output (D) are less precise.
A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin to treat angina. Which statement by the client indicates that further teaching is required?
- A. I may experience flushing but will continue to take the medication as prescribed.
- B. I should lie down before taking the medication.
- C. I should not swallow the tablet.
- D. I will wait to call 911 if I don't experience relief after the third tablet.
Correct Answer: D
Rationale: Delaying 911 after three doses (D) is dangerous; clients should call after no relief from the first dose or after three doses (5 minutes apart). Flushing (A), lying down (B), and not swallowing (C) are correct.
The nurse in a college health clinic is teaching the male students testicular self-examination. Which statement made by one of the young men indicates a need for more teaching?
- A. I should do a testicular self-examination every month.'
- B. When I am taking a shower is a good time to do the self-exam.'
- C. If I feel any lumps, I should report it to the physician.'
- D. Testicular cancer is usually found in older men.'
Correct Answer: D
Rationale: Testicular cancer primarily affects younger men (15–35 years), not older men, indicating a need for more teaching. Monthly exams, shower timing, and reporting lumps are correct.
The client with a colostomy does not feel that the irrigating solution has drained completely. The nurse can enhance the effectiveness of the colostomy irrigation by telling the client to:
- A. Massage the abdomen gently.
- B. Reduce the amount of irrigation solution.
- C. Increase his oral intake.
- D. Place a heating pad on the abdomen.
Correct Answer: A
Rationale: Gentle abdominal massage can stimulate peristalsis and help the irrigation solution drain completely from the colostomy. Reducing solution or using a heating pad is not standard, and increasing oral intake is unrelated.
The unlicensed assistive personnel (UAP) reports to the nurse that during rounds a client has recently become pale. What is the nurse's first action?
- A. Activate the facility's emergency response system
- B. Ask the UAP to obtain a full set of vital signs
- C. Check on the client to collect further data
- D. Immediately notify the health care provider
Correct Answer: C
Rationale: Assessing the client directly (C) confirms the report and guides next steps. Activating emergency response (A), delegating vitals (B), or notifying the provider (D) is premature without assessment.