Nokea
The nurse is applying a hand mitt restraint for a client with pruritis (see fi gure). The nurse should first:
- A. Verify the physician order to use the restraint.
- B. Secure the mitt with ties around the wrist tied to the bed frame.
- C. Place a folded pillow under the wrist.
- D. Place the mitt on top of the hand.
Correct Answer: A
Rationale: Before using any restraints, the nurse must verify that a physician has written an order for the restraint. The mitt does not need to be secured with ties. The client can move the hand as needed. It is not necessary to place a pillow under the wrist. The nurse should place the mitt on the palmer surface of the hand.
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Before a client's discharge after mitral valve replacement surgery, the nurse should evaluate the client's understanding of postsurgery activity restrictions. Which of the following should the client not engage in until after the 1-month postdischarge appointment with the surgeon?
- A. Showering.
- B. Lifting anything heavier than 10 lb.
- C. A program of gradually progressive walking.
- D. Light housework.
Correct Answer: B
Rationale: Lifting heavy objects (>10 lb) risks sternal dehiscence post-mitral valve replacement, so it is restricted until surgeon approval.
When completing the Preoperative Checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first?
- A. Administer the prescribed pre-anesthetic medication.
- B. Note this new allergy prominently at the front of the chart.
- C. Contact the scrub nurse in the operating room.
- D. Inform the nurse anesthetist.
Correct Answer: D
Rationale: A newly discovered allergy must be communicated to the nurse anesthetist first, as it may affect anesthesia choices and prevent allergic reactions during surgery.
Ventricular tachycardia is displayed on the cardiac monitor of a client admitted to the telemetry unit. Which should the nurse do first?
- A. Prepare for immediate cardioversion.
- B. Begin cardiopulmonary resuscitation (CPR).
- C. Check for a pulse.
- D. Prepare for immediate defibrillation.
Correct Answer: C
Rationale: Checking for a pulse determines if ventricular tachycardia is pulseless (requiring defibrillation) or stable (possibly requiring cardioversion or medication).
A 56-year-old client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which of the following symptoms indicates a toxic response to the chemotherapy?
- A. Decrease in appetite.
- B. Drowsiness.
- C. Spasms of the diaphragm.
- D. Cough and shortness of breath.
Correct Answer: D
Rationale: Cough and shortness of breath are hallmark symptoms of pulmonary toxicity, indicating potential lung damage from chemotherapy and requiring immediate attention.
Multiple clients have been brought to the emergency department after being struck by lightning during a severe thunderstorm. Which of the following clients should the nurse prioritize? The client who?
- A. reports numbness and tingling in all their extremities.
- B. has paralysis on both lower extremities.
- C. is confused and cannot remember their name or why they are in the emergency department.
- D. experienced a massive electrical current discharge to their body.
Correct Answer: B
Rationale: Paralysis in both lower extremities indicates potential spinal cord injury or severe neurological damage, requiring immediate prioritization. Numbness and tingling (A) suggest peripheral nerve issues, confusion (C) may indicate concussion or hypoxia, and massive discharge (D) lacks specific clinical urgency without symptoms.