Nokea
The nurse is caring for a client in pain. The nurse asks the client which level of pain he is in, and the client says it's 1 out of 10. The nurse notices that the client grimaces every time he moves. What is the nurse's most appropriate action?
- A. Administer analgesics to the client.
- B. Move on to other patients.
- C. Ask the client about his grimacing with every movement.
- D. Encourage the client to watch his favorite TV show.
Correct Answer: C
Rationale: Grimacing suggests pain despite the low rating, so further assessment clarifies the discrepancy. Administering analgesics, ignoring the issue, or distraction are premature.
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The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 4 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client with progressive multiple sclerosis.
- A. Obtain a referral for occupational therapy for fatigue and energy conservation training
- B. Promote rest by encouraging daytime napping over consistent nighttime sleep
- C. Encourage the client to walk to the mailbox at midday for sun exposure
- D. Instruct the client to increase fluid intake with caffeinated beverages
- E. Obtain an order for physical therapy for home mobility and coordination evaluation
- F. Educate the client on the early signs of cystitis and the importance of completing antibiotics
- G. Educate the client to wear slippers while walking inside
Correct Answer: A,E,F,G
Rationale: Occupational therapy, physical therapy, cystitis education, and slipper use are indicated to address fatigue, mobility, infection prevention, and fall risk. Daytime napping and midday sun exposure are not indicated due to heat sensitivity and inconsistent sleep.
Upon entering a client's room, the nurse finds the client lying on the floor. What is the first action the nurse should implement?
- A. Call for help to get the client back in bed
- B. Assist the client back to bed
- C. Establish if the client is responsive
- D. Ask the client what happened
Correct Answer: C
Rationale: Establishing responsiveness ensures the client’s immediate safety and guides further actions. Other steps follow after assessing the client’s condition.
The nurse has attended a continuing education conference about infection control precautions. It would indicate a correct understanding of the education if the nurse is observed?
- A. using dedicated client-care equipment for a client with Clostridium difficile.
- B. wearing a particulate respirator mask (N95) while caring for a client with epiglottitis, due to Haemophilus influenzae type b.
- C. placing a surgical mask on a client being transported with radiology who has infectious mononucleosis.
- D. keeping the door closed for a client with cryptococcal meningitis.
Correct Answer: A
Rationale: Dedicated equipment for C. difficile prevents transmission. N95 is not needed for epiglottitis, masks are not required for mononucleosis transport, and cryptococcal meningitis does not require a closed door.
The nurse is caring for a post-operative client at risk for a pressure ulcer. Which intervention should the nurse include in the plan of care?
- A. Apply sequential compression devices
- B. Apply an extra sheet to the bed
- C. Position the client on a donut pillow
- D. Encourage the consumption of high-protein foods
Correct Answer: D
Rationale: High-protein foods support tissue repair and collagen synthesis, critical for preventing pressure ulcers in at-risk clients. Sequential compression devices prevent thromboembolism, not pressure ulcers. An extra sheet does not reduce pressure, and donut pillows can increase pressure on surrounding tissues, worsening the risk.
The nurse is caring for a post-operative client at risk for a pressure ulcer. Which intervention should the nurse include in the plan of care?
- A. Apply sequential compression devices
- B. Apply an extra sheet to the bed
- C. Position the client on a donut pillow
- D. Encourage the consumption of high-protein foods
Correct Answer: D
Rationale: High-protein foods support tissue repair and collagen synthesis, critical for preventing pressure ulcers in at-risk clients. Sequential compression devices prevent thromboembolism, not pressure ulcers. An extra sheet does not reduce pressure, and donut pillows can increase pressure on surrounding tissues, worsening the risk.