Nokea
The nurse is caring for a client who is disoriented. To avoid using restraints, the nurse chooses alternative methods to help keep the client oriented. Which interventions would the nurse use for this client? Select all that apply.
- A. maintain normal toileting routines
- B. minimize visitation so that the client may rest
- C. evaluate the client's medications for side effects
- D. keep familiar items such as family pictures near the bedside
- E. use calendars and clocks to orient the client to the date and time
- F. place the client in a room near the end of the hall to minimize noise
Correct Answer: A,C,D,E
Rationale: Toileting routines, medication review, familiar items, and calendars/clocks promote orientation. Minimizing visitation may isolate the client, and room placement is less relevant.
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The nurse is caring for a client who is receiving magnesium sulfate for severe preeclampsia. Which of the following findings would indicate magnesium toxicity?
- A. Respiratory rate of 18 breaths per minute.
- B. Deep tendon reflexes absent.
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 140/90 mmHg.
Correct Answer: B
Rationale: absent deep tendon reflexes are a sign of magnesium toxicity, requiring immediate intervention
A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:
- A. Palms rest lightly on the handles
- B. Elbows are flexed 0°
- C. Client walks to the front of the walker
- D. Client carries the walker
Correct Answer: A
Rationale: Palms resting lightly on the handles ensures proper weight distribution and stability.
The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
- A. Hypoglycemic, small for gestational age
- B. Hyperglycemic, large for gestational age
- C. Hypoglycemic, large for gestational age
- D. Hyperglycemic, small for gestational age
Correct Answer: C
Rationale: Neonates of diabetic mothers are often large for gestational age and at risk for hypoglycemia due to maternal glucose levels.
A nurse has delegated care of a client in wrist restraints to a nursing assistant. The nursing assistant should check the skin circulation under the restraints at least
- A. every 15 minutes.
- B. every 30 minutes.
- C. every hour.
- D. every 2 hours.
Correct Answer: C
Rationale: Restraints require circulation checks every 1-2 hours to prevent skin breakdown or neurovascular injury. Hourly checks (C) balance safety and practicality.
A client with angina is being discharged with a prescription for Transderm Nitro (nitroglycerin) patches. The nurse should tell the client to:
- A. Shave the area before applying the patch
- B. Remove the old patch and clean the skin with alcohol
- C. Cover the patch with plastic wrap and tape it in place
- D. Avoid cutting the patch because it will alter the dose
Correct Answer: B
Rationale: Removing the old patch and cleaning the skin with alcohol ensures proper adhesion and prevents irritation or overdose from residual medication.