Nokea
The nurse is caring for a client who is attempting to leave the hospital against medical advice. The client is competent to make decisions. Which of the following actions would be essential for the nurse to take?
- A. Provide the client with a copy of the client’s medical record
- B. Tell the client that discharge forms must be signed before leaving
- C. Inform the client that the client cannot return for medical care after leaving
- D. Ensure the health care provider explains the risks of leaving the hospital to the client
Correct Answer: D
Rationale: Ensuring the provider explains risks ensures informed decision-making, protecting the client and minimizing liability. Medical records are not immediately provided, forms are procedural, and barring future care is incorrect.
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The nurse is reinforcing teaching about foot care for a group of clients with diabetes mellitus. Which of the following information should the nurse include? Select all that apply.
- A. Dry the feet vigorously with a towel after bathing
- B. Use an over-the-counter kit to treat corns and calluses
- C. Use cotton or lamb’s wool to separate overlapping toes
- D. Wash the feet with lukewarm water
- E. Wear hard-sole shoes and do not go barefoot
Correct Answer: C,D,E
Rationale: Using cotton/wool for toes prevents pressure sores, lukewarm water avoids burns, and hard-sole shoes protect feet. Vigorous drying risks skin breakdown, and over-the-counter kits can cause injury in diabetic feet with poor sensation.
The nurse is assisting with the care of a newborn during circumcision. Which intervention is appropriate?
- A. Anticipate the use of clean technique during the circumcision
- B. Apply a snug-fitting diaper following the procedure
- C. Offer a bottle during the procedure
- D. Wrap the newborn’s upper body in a blanket for the circumcision
Correct Answer: D
Rationale: Wrapping the upper body keeps the newborn warm and secure during circumcision. Sterile technique is required, snug diapers risk irritation, and feeding during the procedure poses a choking risk.
A client is admitted to the burn unit with an electrical burn. Which of the following areas probably sustained the greatest degree of injury?
- A. The skin
- B. The intrathoraxic
- C. The muscles supporting the long bones
- D. The bones
Correct Answer: B
Rationale: Electrical burns cause deep tissue damage, with intrathoracic organs (heart, lungs) at greatest risk due to the current's path through the body.
The nurse is evaluating how a client who has a halo brace is reacting to this change in his body image. Which statement by the client indicates a need for additional support in adjusting to the brace?
- A. I shall avoid going out in public since I may bump into people.'
- B. I don't mind that people look at me.'
- C. I told my grandchildren that this looks like a space helmet.'
- D. I like to sleep in the reclining chair that we have.'
Correct Answer: A
Rationale: Avoiding public interaction suggests poor adjustment to the halo brace, indicating a need for support to address body image concerns.
What nursing action is essential when oxygen is ordered for a client who is living at home?
- A. Assist the client and family in checking all electrical appliances in the vicinity for frayed cords.
- B. Encourage the client and family to purchase fire extinguishers.
- C. Remove electrical devices from the room where oxygen is in use.
- D. Encourage the client and family to carpet the client's room.
Correct Answer: A
Rationale: Checking for frayed cords reduces fire risk, as oxygen supports combustion. Extinguishers are secondary, removing devices is impractical, and carpeting increases static sparks.