Nokea
The nurse is caring for a client with increased intracranial pressure (ICP). Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse?
- A. I will raise the head of the bed so it is easier to see the television.
- B. I will turn down the lights when I leave.
- C. Let me move your belongings closer so you can reach them
- D. You should do deep breathing and coughing exercises.
Correct Answer: A
Rationale: Raising the head of the bed (A) without medical guidance can alter ICP dangerously. Dimming lights (B), moving belongings (C), and breathing exercises (D) are generally safe or neutral.
You may also like to solve these questions
A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first?
- A. Auscultate breath sounds
- B. Check for peripheral edema
- C. Measure the client's vital signs
- D. Review the client's weight log over the past several days
Correct Answer: A
Rationale: Auscultating breath sounds (A) assesses the cause of breathlessness (e.g., pulmonary edema) in heart failure, guiding immediate interventions. Edema (B), vitals (C), and weight (D) are secondary.
The nurse in the emergency department is caring for a client who has facial lacerations, a suspected fracture of the arm, and multiple bruises at various stages of healing. The client's spouse is at the bedside and appears angry. Which of the following actions would be a priority for the nurse take?
- A. Recommend a referral to social services for the client.
- B. Talk with the client privately without the spouse in the room.
- C. Place the client's arm in a shoulder sling and prepare the client for an x-ray.
- D. Cleanse the client's facial lacerations and prepare to assist with suture placement.
Correct Answer: B
Rationale: Multiple bruises at various stages suggest possible abuse, so talking privately with the client (B) is the priority to assess safety. Social services (A) may follow, but immediate safety assessment comes first. Treating injuries (C, D) is secondary.
The nurse has attended a staff education program about administering intramuscular injections. Which of the following statements by the nurse would indicate a correct understanding of the program?
- A. I will insert the needle at a 45-degree angle.
- B. I will wait 3 seconds after injecting the medication before removing the needle.
- C. I will gently massage the injection site after removing the needle.
- D. I will use my hand to displace subcutaneous tissue prior to inserting the needle.
Correct Answer: D
Rationale: Displacing subcutaneous tissue (D) via the Z-track method prevents leakage and irritation. IM injections use a 90-degree angle (A is incorrect), waiting 3 seconds (B) is not standard, and massaging (C) is avoided for some medications.
The nurse has been teaching a woman who has iron deficiency anemia. Which menu, if selected, indicates that the woman understands her dietary instructions?
- A. Applesauce, green beans, bread, and butter
- B. Peanut butter and jelly sandwich, carrots, and milk
- C. Broccoli, spinach salad with tomatoes, and orange juice
- D. Macaroni and cheese, pickles, and hot chocolate
Correct Answer: C
Rationale: Broccoli, spinach, and orange juice (vitamin C enhances iron absorption) are iron-rich, ideal for anemia. Other menus lack sufficient iron sources.
The nurse is caring for all of the following persons. Which one is most in need of restraints?
- A. An elderly man who is sitting in a chair
- B. A confused postoperative client who is picking at his nasal oxygen and nasogastric (NG) tube
- C. A confused woman who is in bed with the side rails up
- D. An adult who has just returned to the surgical floor from a postanesthesia care unit
Correct Answer: B
Rationale: The confused postoperative client risks dislodging critical tubes, necessitating restraints if non-restraint interventions fail. Others pose lower immediate risk.