Nokea
The nurse is applying soft wrist restraints to a client who is violent towards the nursing staff. Which actions by the nurse are appropriate? Select all that apply.
- A. Places a pair of scissors at the bedside for emergent discontinuation.
- B. Positions the client supine after applying both wrist restraints.
- C. Releases both restraints at the same time, every two hours.
- D. Informs the client of the behavior necessary to demonstrate to end the restraints.
- E. Ensures two fingers can be placed under each restraint.
Correct Answer: D,E
Rationale: Informing the client of expected behavior and ensuring a two-finger gap promote safety and compliance. Scissors are unsafe, supine positioning is not required, and simultaneous release is impractical.
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The nurse instructed a client discharged with crutches on how to use the stairs. Which statement by the client indicates a correct understanding of the teaching?
- A. I should hold the handrail for support with one hand.
- B. When going up the stairs, I should lead with my crutches and weaker leg.
- C. When going down the stairs, I should lead with my crutches and strong leg.
- D. I should remove the rubber tip when going up and down the stairs.
Correct Answer: A
Rationale: Holding the handrail provides stability. Ascending requires leading with the stronger leg, descending with crutches and weaker leg, and rubber tips remain on.
The charge nurse is observing infection control practices in the nursing unit. Which observation by the charge nurse requires follow-up? Select all that apply.
- A. Soiled linens are placed on the floor during a bed bath and linen change.
- B. A disposable blood pressure cuff is used for a client on contact precautions.
- C. Disposable dishes are placed in the room for a client on droplet precautions.
- D. Reusable eye protection is cleaned and disinfected after each client encounter.
- E. A surgical hand scrub is performed with the hands lower than the elbows.
- F. Gloves are doffed last while removing personal protective equipment (PPE).
Correct Answer: A,E,F
Rationale: Soiled linens on the floor risk contamination, hands should be higher than elbows during surgical scrub, and gloves should be doffed first to prevent contamination.
The nurse is providing preoperative teaching to a client scheduled for a pneumonectomy. Which of the following statements should the nurse make to the client?
- A. You must lay on your nonoperative side immediately following this surgery
- B. You can expect your lung function to return to normal within two to six hours
- C. You will want to avoid coughing after this surgery as you will be suctioned using a catheter
- D. You will be encouraged to get up and walk the same day as your surgery
Correct Answer: D
Rationale: Early ambulation post-pneumonectomy promotes lung expansion, prevents complications like pneumonia, and aids recovery. Lying on the nonoperative side is not universally required, lung function does not return to normal in hours, and coughing is encouraged to clear secretions, not avoided.
A nurse is taking care of a client undergoing cerebral angiography. Which statement by the client would require immediate follow-up?
- A. I feel like I'm going to vomit.
- B. I hope my results are okay.
- C. It's getting a bit hot in here.
- D. My throat is getting a bit itchy, and my eyes are getting watery.
Correct Answer: D
Rationale: Itchy throat and watery eyes suggest an allergic reaction to the contrast dye, requiring immediate intervention. Nausea, hopefulness, and feeling warm are less urgent.
The nurse is educating the parents of a child who plans on riding their bicycle. Which statements, if made by the parents, indicate effective understanding?
- A. I should tell my child to ride their bike against the traffic pattern.
- B. I should instruct my child to walk their bike through busy intersection crosswalks.
- C. Wearing a helmet is only necessary when my child is riding near a busy intersection.
- D. My child can ride their bike barefoot as long as it's short distances.
Correct Answer: B
Rationale: Walking the bike through busy intersections enhances safety. Riding against traffic, optional helmet use, and barefoot riding are unsafe.