Nokea
The nurse is caring for a client with dementia who has pulled out three peripheral IVs. Which intervention by the nurse is the best way to manage this client?
- A. place the client in restraints or mitts
- B. tell the family that they need to stay with the client
- C. replace the IV and wrap it in gauze to hide it from view
- D. tell the client that if she pulls another IV out, she will have to have a PICC line placed
Correct Answer: C
Rationale: Wrapping the IV in gauze hides it from view, reducing the likelihood of the client pulling it out, while being less invasive than restraints or threats.
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The nurse is preparing to admit a client from the emergency department with tuberculosis. Which of the following should the nurse anticipate in caring for this client? Select all that apply.
- A. fall precautions
- B. droplet precautions
- C. airborne precautions
- D. standard precautions
- E. placement in a negative airflow room
- F. use of PPE, including an N95 mask or powered air purifying respirators (PAPRs)
Correct Answer: C, D, E, F
Rationale: Tuberculosis requires airborne precautions, standard precautions, negative airflow rooms, and N95/PAPR use due to respiratory transmission. Fall precautions are not specific, and droplet precautions are incorrect.
The nurse is completing admission on a client with possible esophageal cancer. Which finding would not be common for this diagnosis?
- A. Foul breath
- B. Dysphagia
- C. Diarrhea
- D. Chronic hiccups
Correct Answer: C
Rationale: Esophageal cancer commonly presents with dysphagia, foul breath (due to tumor necrosis), and chronic hiccups (from diaphragmatic irritation). Diarrhea is not typically associated with esophageal cancer.
An older adult has become very confused after surgery for repair of a hip fracture. The client has repeatedly tried to climb over the bedrails and the nurse is considering placing the client in a Posey vest that is secured to the bed. Which of the following must the nurse consider when applying restraints to a client? Select all that apply.
- A. An alternate method should be tried prior to applying a restraint.
- B. Confused clients are almost always safer in restraints.
- C. Restraints must be removed and the client reassessed at least every 2 hours.
- D. A written policy for application of restraints must be in place.
- E. The most restrictive restraint should be applied.
- F. The nurse does not need an order for a restraint if the client is in danger.
Correct Answer: A,C,D
Rationale: Alternatives (A), reassessment every 2 hours (C), and a written policy (D) are required for restraints. Confused clients aren't always safer (B), most restrictive (E) is incorrect, and an order is needed (F).
The nurse is caring for a postpartum client 2 hours post-delivery who is unable to void. Which of the following nursing interventions should be considered initially?
- A. Insert a straight catheter for residual
- B. Encourage oral intake of fluids
- C. Check perineum for swelling or hematoma
- D. Palpate bladder for distention and position
Correct Answer: D
Rationale: Palpating the bladder assesses for distention, which may indicate urinary retention, guiding further interventions without immediately resorting to invasive measures.
The nurse is preparing to discharge a client diagnosed with gout. Which statement by the client indicates understanding of dietary restrictions while managing gout?
- A. I should avoid beer, anchovies, and liver.
- B. I should avoid bananas, grapefruit, and oranges.
- C. I should avoid dairy products such as milk and ice cream.
- D. I should avoid red wine, dark chocolate, and aged cheeses.
Correct Answer: A
Rationale: Beer, anchovies, and liver are high in purines, which exacerbate gout. Other foods listed are not primary triggers.