Nokea
The nurse is caring for a client with a history of falls.
- A. Which intervention should be included in the care plan for a client with a history of falls?
- B. Keep the bed in a high position to discourage getting out of bed.
- C. Encourage the client to remain in bed as much as possible.
- D. Place a night light in the bathroom.
- E. Restrict the client’s fluid intake in the evening.
Correct Answer: C
Rationale: A night light in the bathroom reduces fall risk by improving visibility during nighttime ambulation, a common time for falls. High bed positions and bed rest increase fall risk, and fluid restriction is unrelated to fall prevention.
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A client is receiving a nitroglycerin infusion for unstable angina. What assessment would be a priority when monitoring the effects of this medication?
- A. Blood pressure
- B. Cardiac enzymes
- C. ECG analysis
- D. Respiratory rate
Correct Answer: A
Rationale: Since an effect of this drug is vasodilation, the client must be monitored for hypotension.
The provisions of the law for the Americans with Disabilities Act require nurse managers to
- A. Maintain an environment free from associated hazards
- B. Provide reasonable accommodations for disabled individuals
- C. Make all necessary accommodations for disabled individuals
- D. Consider both mental and physical disabilities
Correct Answer: B
Rationale: The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's ability to perform the job and not discriminate on the basis of a disability. Employers also must make 'reasonable accommodations.'
Promethazine hydrochloride (Phenergan) 25 mg IV push has been ordered for a patient. Before administering this medication to the patient, the nurse should check the
- A. color of the medication solution.
- B. patient's pulse and temperature.
- C. time of the last analgesic dose the patient received.
- D. patency of the patient's vein.
Correct Answer: D
Rationale: is very important to determine absolute patency of the vein; extravasation will cause necrosis
When assessing a client who has just undergone a cardioversion, the practical nurse (LPN) finds the respirations are 12/minute. Which action should the nurse take first?
- A. Try to vigorously stimulate normal breathing
- B. Ask the RN to assess the vital signs
- C. Measure the pulse oximetry
- D. Continue to monitor respirations
Correct Answer: D
Rationale: Continue to monitor respirations. A rate of 12/minute is acceptable post-cardioversion, requiring no immediate intervention.
A nurse is doing preconception counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?
- A. I understand that a glass of wine with dinner is healthy.
- B. Beer is not really hard alcohol, so I guess I can drink some.
- C. If I drink, my baby may be harmed before I know I am pregnant.
- D. Drinking with meals reduces the effects of alcohol.
Correct Answer: C
Rationale: If I drink, my baby may be harmed before I know I am pregnant. This reflects awareness of alcohol's early fetal risks.