Nokea
The nurse is caring for a client in bilateral soft wrist restraints. The nurse should assess the client's? Select all that apply.
- A. behavioral status.
- B. skin integrity.
- C. bowel sounds.
- D. neurovascular status.
- E. need for restraint.
Correct Answer: A,B,D,E
Rationale: Behavioral status, skin integrity, neurovascular status, and need for restraint must be assessed to ensure safety and appropriateness of restraints. Bowel sounds are unrelated.
You may also like to solve these questions
The nurse is teaching a group of students on incident reports. Which of the following situations would require an incident report? Select all that apply.
- A. Requesting to view their medical record.
- B. Complaining about poor care from a nurse.
- C. Leaving against medical advice (AMA).
- D. Requesting an increase in pain medication.
- E. Threatening a nurse with bodily harm.
Correct Answer: B,C,E
Rationale: Complaints about care, AMA, and threats require incident reports to document potential risks or issues. Viewing records and requesting medication changes do not.
The nurse is preparing to administer a low-cleansing enema to a client. Which action by the nurse is appropriate during the administration of the enema?
- A. Administer the enema with the client in a supine position.
- B. Insert the enema tube 2 inches into the rectum.
- C. Use cold tap water for the enema solution.
- D. Hang the enema bag approximately 12 inches above the client's rectum.
Correct Answer: D
Rationale: Hanging the bag 12 inches above the rectum ensures proper flow. Supine position is incorrect, insertion is 3-4 inches, and cold water causes cramping.
The nurse is caring for a client who has been physically violent towards staff. The nurse prepares to restrain the client using
- A. soft wrist restraints.
- B. mitten restraints.
- C. elbow restraints.
- D. waist belt restraint.
Correct Answer: A
Rationale: Soft wrist restraints are appropriate for preventing harm in violent clients while allowing some movement. Other options are less suitable.
The nurse is reviewing a newly hired nurse's understanding of sterile technique. Which statement, if made by the newly hired nurse, would indicate effective understanding? Select all that apply.
- A. I should open sterile packages away from my body.
- B. If the sterile field gets contaminated, I should dispose of everything and start over.
- C. One inch (2.5 cm) border around a sterile drape can be touched with clean fingers.
- D. I should apply sterile gloves on my non-dominant hand first.
- E. An object placed below my waist is considered contaminated.
Correct Answer: A,B,D,E
Rationale: Opening packages away, restarting after contamination, applying gloves correctly, and recognizing below-waist contamination are correct. The 1-inch border is non-sterile and should not be touched.
The nurse is discussing mass casualties with a group of nursing students. Which statement by the student would indicate effective understanding? Select all that apply.
- A. Mass casualties are events that overwhelm local medical capabilities.
- B. When a mass casualty occurs, there is a need to increase the staff at the hospital.
- C. Many local agencies will collaborate to handle a mass casualty situation.
- D. An example of a mass casualty event is a fight between visitors in the intensive care unit.
- E. Staff preferences for client assignments should prioritize over client needs.
Correct Answer: A,B,C
Rationale: Mass casualties overwhelm resources, require more staff, and involve multi-agency collaboration. A visitor fight is not a mass casualty, and client needs take priority.