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The nurse is caring for a client with bipolar disorder who is hospitalized for an acute manic episode. Which of the following actions would the nurse expect to be included in the client's plan of care? Select all that apply.
- A. Ask the client to plan an outing for the unit
- B. Assign the client to a private room
- C. Assist client in choosing appropriate clothing
- D. Include the client in group therapy sessions
- E. Schedule the client for physical activity with a staff member
- F. Seat the client with other clients in the dining room for meals
Correct Answer: B,C,D,E,F
Rationale: During a manic episode, a private room (B) minimizes stimuli, appropriate clothing (C) supports dignity, group therapy (D) fosters socialization, physical activity (E) channels energy, and dining with others (F) promotes normalcy. Planning an outing (A) is inappropriate due to impulsivity risks.
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The nurse is talking with a client with stable angina who has a prescription for sublingual nitroglycerin. Which of the following statements by the client would require follow-up?
- A. I shall sit down if possible before taking this medication to prevent dizziness.
- B. I may experience flushing or a headache when taking this medication.
- C. I will avoid taking the medication with grapefruit juice.
Correct Answer: C
Rationale: Nitroglycerin is not contraindicated with grapefruit juice (C), indicating a misunderstanding. Sitting down (A) prevents falls from hypotension, and flushing/headache (B) are expected side effects, both correct.
The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply.
- A. Do not leave a tourniquet on more than 1 minute while looking for a vein
- B. Draw the specimen while the skin is still wet with the alcohol prep
- C. If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes
- D. Use a highly visible vein on the ventral side of the client's wrist
- E. Vigorously shake the specimen tube to mix obtained blood with anticoagulant solution
Correct Answer: A,C
Rationale: A tourniquet left on too long (A) can cause hemoconcentration, so it should be removed after 1 minute. Pulsating blood (C) indicates arterial puncture, requiring immediate needle withdrawal and pressure to prevent hematoma. Wet alcohol (B) can cause hemolysis, and the ventral wrist (D) is a risky site due to nerves and arteries. Vigorous shaking (E) damages blood cells, so gentle inversion is preferred.
A client with allergic rhinitis has an order for a long-acting nasal spray that contains oxymetazoline. The client should be instructed to use the spray as directed to prevent:
- A. Bleeding tendencies
- B. Increased nasal congestion
- C. Nasal polyps
- D. Tinnitus
Correct Answer: B
Rationale: Overuse of oxymetazoline can cause rebound nasal congestion (rhinitis medicamentosa). It does not typically cause bleeding, nasal polyps, or tinnitus.
All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which duties are appropriate for the licensed practical nurse to delegate to unlicensed assistive personnel to promote client safety? Select all that apply.
- A. Educate newly admitted client on the importance of using the call light for assistance
- B. Place the bedside commode as close to the bed as possible
- C. Remind client to change position slowly
- D. Report observations of changes in client’s condition immediately
- E. Report whether client is using correct gait and balance while ambulating with walker
Correct Answer: B,C,D
Rationale: UAP can place commodes (B), remind about slow position changes (C), report condition changes (D), and observe gait (E). Education (A) requires nursing judgment, unsuitable for delegation.
At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially
- A. Allow the staff to change assignments
- B. Identify reasons for current assignments
- C. Help staff see the complexity of issues
- D. Facilitate creative thinking on staffing
Correct Answer: D
Rationale: Facilitate creative thinking on staffing. The 'moving phase' of change involves viewing the problem from a new perspective, and then incorporating new and different approaches to the problem. The manager, as a change agent, can facilitate staff's solving the problem.