Nokea
The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? Select all that apply
- A. One family member has gone to lunch.
- B. Patient is placed in bilateral wrist restraints at 0815.
- C. Bilateral radial pulses present, 2+, hands warm to touch
- D. Straps with quick-release buckle attached to bed side rails
- E. Attempts to distract the patient with television are unsuccessful.
- F. Released from restraints, active range-of-motion exercises completed.
Correct Answer: B, C, E, F
Rationale: The correct answers are B, C, E, and F.
B: Documenting the time and type of restraints applied is essential for monitoring and ensuring proper care.
C: Assessing and documenting the patient's radial pulses and skin temperature in restraints is crucial to monitor circulation and skin integrity.
E: Documenting unsuccessful attempts to distract the patient with television helps identify alternative strategies for patient management.
F: Documenting the release from restraints and completion of range-of-motion exercises ensures proper follow-up care and monitoring.
Incorrect choices:
A: Not relevant to the patient's care in restraints.
D: Describes the equipment used but does not provide information on the patient's condition or care.
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Nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which bed position is appropriate for safe care of this client?
- A. Supine
- B. Semi-Fowler's
- C. Semi-prone
- D. Trendelenburg
Correct Answer: B
Rationale: The correct answer is B: Semi-Fowler's. This position helps prevent aspiration during enteral tube feedings by promoting proper digestion and reducing the risk of reflux. Semi-Fowler's allows gravity to assist in the movement of food through the gastrointestinal tract, decreasing the likelihood of regurgitation. Supine (A) can increase the risk of aspiration as it may cause reflux. Semi-prone (C) and Trendelenburg (D) positions are not recommended for enteral feedings due to increased risk of reflux and aspiration.
A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse consider?
- A. Loss of bone mass
- B. Loss of strength
- C. Loss of weight
- D. Loss of hope
Correct Answer: D
Rationale: The correct answer is D: Loss of hope. When a patient is immobile, they may experience feelings of hopelessness, leading to negative psychosocial impacts. The nurse must address this aspect in the care plan to promote the patient's mental well-being. Loss of bone mass (A), loss of strength (B), and loss of weight (C) are physical aspects related to immobility, not psychosocial. These factors are important but do not directly address the patient's emotional state. It is crucial for the nurse to focus on the psychosocial well-being of the patient to provide holistic care.
Nurse is caring for client with SARS. Nurse is aware that healthcare professionals are required to report communicable & infectious diseases. Which of these illustrate rationale for reporting?
- A. Planning & evaluating control & prevention strategies
- B. Determining public health priorities
- C. Ensuring proper medical treatment
- D. Identifying endemic disease
- E. Monitoring for common-source outbreaks
Correct Answer: A,B,C,E
Rationale: The correct answer is A, B, C, and E. Reporting communicable diseases like SARS is essential for planning and evaluating control and prevention strategies. It helps determine public health priorities by identifying areas of concern. Reporting ensures proper medical treatment for affected individuals and helps in monitoring for common-source outbreaks to prevent further spread. Choices D, F, and G are incorrect as they do not directly relate to the rationale for reporting communicable diseases. Identifying endemic diseases may be a part of reporting, but it is not the primary reason.
Nurse reviewing CDC's immunizations recommendations with middle adult. Which should nurse include in this discussion? (Select all that apply.)
- A. Haemophilus influenzae type b
- B. Varicella
- C. Herpes zoster
- D. HPV
- E. Seasonal influenza
Correct Answer: B,C,E
Rationale: The correct choices for the nurse to include in the discussion with the middle adult are Varicella, Herpes zoster, and Seasonal influenza. Varicella (chickenpox) and Herpes zoster (shingles) are important vaccinations to prevent these viral infections, especially in middle-aged adults who may be at higher risk. Seasonal influenza vaccination is also crucial for middle adults to protect against flu-related complications. Haemophilus influenzae type b is typically given to children under 5, so it is not relevant for this age group. HPV vaccination is recommended for younger individuals to prevent certain cancers.
Nurse observes smoke coming from under the door of the staff lounge. What is the priority action by the nurse?
- A. Extinguish fire
- B. Pull fire alarm
- C. Evacuate the clients
- D. Close all open doors on the unit
Correct Answer: C
Rationale: The correct answer is C: Evacuate the clients. This is the priority action because ensuring the safety of the clients is the nurse's primary responsibility. Evacuating the clients from the area of potential danger is crucial to prevent harm. A: Extinguishing the fire should be left to trained personnel. B: Pulling the fire alarm is important, but evacuating clients takes precedence. D: Closing doors may help contain the fire but doesn't ensure immediate safety.