Nokea
The nurse is assigned to care for a client with a diagnosis of preeclampsia. The nurse should plan to implement which action to provide a safe environment?
- A. Maintain fluid and sodium restrictions.
- B. Take the client's vital signs every 4 hours.
- C. Turn off the room lights and draw the window shades.
- D. Encourage visits from family and friends for psychosocial support.
Correct Answer: C
Rationale: Clients with preeclampsia are at risk of developing eclampsia (seizures). Bright lights and sudden loud noises may initiate seizures in this client. A woman with preeclampsia should be placed in a dimly lighted, quiet, private room. Clients with preeclampsia have decreased plasma volume, and adequate fluid and sodium intake is necessary to maintain fluid volume and tissue perfusion. Vital signs need to be monitored more frequently than every 4 hours when preeclampsia is present. Visitors should be limited to allow for rest and prevent overstimulation.
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The nurse manager is providing an educational session to the nursing staff on the safe use of physical restraints. Which are examples of safety guidelines when using physical restraints? Select all that apply.
- A. Restraints should be secured with a quick-release tie.
- B. A primary health care provider's prescription is required.
- C. Restraints are secured to side rails so that they can be easily removed as necessary.
- D. Restraints are used when other measures have failed to prevent selfinjury or injury to others.
- E. Restraints can be used as a usual part of treatment plans, as indicated by the client's condition or symptoms.
- F. The use of restraints can be prescribed PRN (as needed) as long as the nurse performs a thorough assessment before applying them.
Correct Answer: A,B,D
Rationale: A physical restraint is a mechanical or physical device that is used to immobilize a client or extremity. It restricts the freedom of movement or normal access to a client's body. A primary health care provider's prescription is required for the use of restraints. Restraints should be secured with a quickrelease tie so that they can be easily removed in an emergency. Restraints are considered for use only when other measures have failed to prevent self-injury or injury to others. Restraints are secured to the bed frame, not the side rails, because the client may be injured if the side rail is lowered. Restraints, not a usual part of treatment plans, may be indicated by the person's condition or symptoms, and are not prescribed on a PRN basis.
The nurse is planning the discharge instructions for an adult client who is a victim of family violence. The nurse should understand that it is most important that which information is included in the discharge plans?
- A. Instructions to call the police the next time the abuse occurs
- B. Exploration of the pros and cons of remaining with the abusive family member
- C. Specific information regarding 'safe havens' or shelters in the client's neighborhood
- D. Specific information about current opportunities to enroll in local selfdefense classes
Correct Answer: C
Rationale: For the victim of family violence, any of the options might be included in the discharge plan at some point if long-term therapy or a long-term relationship with the nurse is established. The question refers to an emergency department setting. It is most important to assist victims of abuse with identifying a plan for how to remove self from harmful situations should they arise again. An abused person is usually reluctant to call the police. It is not the best time for the nurse to explore the pros and cons of remaining with the abusive family member; additionally, this action does not ensure safety for the victim. Teaching the victim to fight back (as in the use of self-defense) is not the best action when dealing with a violent person.
The registered nurse (RN) planning the assignments for the day is leading a team composed of a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Based on licensure, which client is most appropriate to assign to the LPN?
- A. A client diagnosed with dementia
- B. A 1-day postoperative mastectomy client
- C. A client who requires some assistance with bathing
- D. A client who requires some assistance with ambulation
Correct Answer: B
Rationale: Assignment of tasks must be implemented based on the job description of the LPN and UAP, the level of education and clinical competence, and state law. The 1-day postoperative mastectomy client will need care that requires the skill of a licensed nurse. The UAP has the skills to care for a client requiring noninvasive care such as a client with dementia, a client who requires some assistance with bathing, and a client who requires some assistance with ambulation.
Which clinical situation should the nurse identify as an example of slander?
- A. The primary health care provider tells a client that the nurse 'does not know anything.'
- B. The nurse tells a client that a nasogastric tube will be inserted if the client continues to refuse to eat.
- C. The nurse restrains a client at bedtime because the client gets up during the night and wanders around.
- D. The laboratory technician restrains the arm of a client refusing to have blood drawn so that the specimen can be obtained.
Correct Answer: A
Rationale: Defamation takes place when a falsehood is said (slander) or written (libel) about a person that results in injury to that person's good name and reputation. Battery involves offensive touching or the use of force by a perpetrator without the permission of the victim. An assault occurs when a person puts another person in fear of a harmful or offensive act.
To ensure that the client self-administers medications safely in the home, which action plan should the nurse implement?
- A. Perform a pill count of each prescription bottle at every home visit.
- B. Instruct the client to double up on a medication when a dose is missed.
- C. Provide information on the purpose of all the prescribed medications.
- D. Ask the client to explain and demonstrate self-administration procedures.
Correct Answer: D
Rationale: To ensure safe administration of medication, the nurse asks the client to explain and demonstrate correct self-administration of medication procedures because demonstrating the proper procedure for the client does not ensure that the client can safely perform any procedure. Usually it is not acceptable to double up on missed medication and conducting a pill count on each visit is unrealistic and disrespectful.