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The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? (Select all that apply)
- A. Raise the four side rails on the bed.
- B. Close the client's room door.
- C. Orient the client to the surroundings.
- D. Secure a bed alarm on the mattress.
- E. Escort the client back to her room.
Correct Answer: C,D,E
Rationale: Orienting, alarming, and escorting ensure safety.
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The healthcare provider prescribes nasogastric tube (NGT) insertion for a client with a postoperative ileus. During insertion, the client begins to gag. Which action should the nurse take?
- A. Use firm pressure to pass the tube through the glottis.
- B. Have the client tilt head backward to open the passage.
- C. Give the client a few sips of water to drink.
- D. Remove the tube and attempt reinsertion.
Correct Answer: D
Rationale: Removing and reinserting prevents discomfort and harm.
A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?
- A. Elevate the area and apply light pressure over the site.
- B. Apply a cold pack to the area for twenty minutes.
- C. Document the site where the medication was given.
- D. Notify the healthcare provider of the allergic response.
Correct Answer: C
Rationale: Documenting confirms normal intradermal reaction.
The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?
- A. White blood cell count.
- B. Serum sodium levels.
- C. Serum potassium levels.
- D. Creatinine clearance.
Correct Answer: B
Rationale: Excess water dilutes sodium, risking hyponatremia.
During the prodromal stage of an infection, which is the priority nursing intervention?
- A. Develop a plan for gradually increasing activity and mobility.
- B. Begin discharge planning and teaching.
- C. Implement precautions to prevent disease transmission.
- D. Offer the client frequent fluids and ice chips.
Correct Answer: C
Rationale: Precautions prevent infection spread.
Which assessment is most important for the nurse to perform prior to the application of a heating pad?
- A. Muscle strength and tone.
- B. Presence of rebound phenomenon.
- C. Limitations to range of motion.
- D. Degree of neurosensory impairment.
Correct Answer: D
Rationale: Neurosensory impairment risks burns.