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The nurse is caring for a client scheduled for electroconvulsive therapy (ECT). To prevent complications during and after the procedure, the nurse should assess the client's
- A. sensation in the lower extremities
- B. dentition
- C. grip strength
- D. peripheral vision
Correct Answer: B
Rationale: Assessing dentition is critical before ECT to identify loose teeth or dental appliances that could pose an airway risk during induced seizures. Sensation, grip strength, and peripheral vision are not directly related to ECT complications.
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The nurse has attended a conference on intraoperative nursing interventions for the older adult. which of the following statements by the nurse would indicate the need for additional teaching?
- A. Warming devices should be used to prevent the client from developing hypothermia
- B. The client's head and feet should be covered during surgery
- C. Clients should be slid, not lifted into the proper position
- D. Providing extra padding for clients with decreased peripheral circulation is important
Correct Answer: C
Rationale: Sliding clients instead of lifting can cause shear injuries, particularly in older adults with fragile skin. Warming devices, covering extremities, and extra padding are appropriate to prevent hypothermia and protect pressure points, indicating correct understanding.
The nursing instructor is supervising a nursing student feeding a client at risk for aspiration. Which action by the nursing student requires follow-up by the nursing instructor? Select all that apply.
- A. Instructs the client to tilt the head backward when drinking.
- B. Reminds the client to assume a chin-down position.
- C. Provides rest periods as needed during the meal.
- D. Positions the client upright for 30-60 minutes after a meal.
- E. Positions the head of the bed at a 45-degree angle during the meal.
Correct Answer: A
Rationale: Tilting the head backward increases aspiration risk. Chin-down position, rest periods, upright positioning, and 45-degree elevation are appropriate.
The nurse participates in a task force to reduce errors related to telephone and verbal orders. The nurse should recommend that
- A. unlicensed assistive personnel (UAP) can take a physician's telephone prescription.
- B. use more abbreviations when transcribing a physician's order.
- C. when repeating an order back to the physician, repeat the numbers individually.
- D. verbal and telephone orders are limited to emergency situations.
- E. transcribing telephone and verbal orders be delayed until a second nurse can review the order.
Correct Answer: C,D
Rationale: Repeating numbers individually and limiting verbal orders to emergencies reduce errors. UAP cannot take prescriptions, abbreviations increase errors, and delays risk patient safety.
The nurse is caring for a client who has been on bed rest for 2 days following surgery. To prevent complications associated with the client's first ambulation, the nurse should plan to
- A. Encourage the client to increase fluid intake to at least 2,000 mL per day.
- B. Assist the client in performing range-of-motion (ROM) exercises.
- C. Teach the client how to use the incentive spirometer.
- D. Encourage the client to dangle their legs at the bedside.
Correct Answer: D
Rationale: Dangling legs at the bedside prevents orthostatic hypotension during first ambulation. Fluids, ROM, and spirometry are supportive but not specific to ambulation.
The nurse is caring for a client who underwent moderate sedation for a closed shoulder reduction. The nurse reviews the client’s clinical data. Which post-procedure data requires immediate followup?
- A. Blood Pressure
- B. Glasgow Coma Scale
- C. Respirations
- D. Temperature
Correct Answer: C
Rationale: Respiratory depression is a critical risk post-moderate sedation, so abnormal respirations require immediate follow-up. Blood pressure, Glasgow Coma Scale, and temperature are important but secondary unless specific abnormalities are noted.