Nokea
The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply.
- A. Ensuring bed alarm remains activated
- B. Initiating an hourly rounding schedule
- C. Inserting an indwelling urinary catheter
- D. Moving client to a room close to the nurses' station
- E. Raising all side rails of the client's bed
Correct Answer: A,B,D
Rationale: Bed alarms (A), hourly rounding (B), and proximity to the nurses' station (D) enhance safety and monitoring. Catheters (C) increase infection risk and are not first-line, and raising all side rails (E) is a restraint and unsafe.
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A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.4 kg) over the last 2 days. Which information is most important for the nurse to ask this client?
- A. Diet recall for this current week
- B. Fluid intake for the past 2 days
- C. Medications and dosages taken over the past 2 days
- D. Presence of shortness of breath, coughing, or edema
Correct Answer: D
Rationale: Symptoms like shortness of breath, coughing, or edema (D) indicate fluid overload, a critical concern in heart failure. Diet (A), fluid intake (B), and medications (C) are relevant but secondary.
An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?
- A. Review the client's weight pattern over the year
- B. Ask the mother to record her diet for the last 24 hours
- C. Encourage her to talk about her view of herself
- D. Give her several pamphlets on postpartum nutrition
Correct Answer: C
Rationale: Encourage her to talk about her view of herself. To an adolescent, body image is very important, and addressing this concern first facilitates further assessment.
The clinic nurse is caring for a client who had cataract surgery with intraocular lens implantation 2 days ago. Which client report requires priority intervention?
- A. Blurry vision in the affected eye
- B. Constipation
- C. Itching in the affected eye
- D. Sleeping on 2 pillows at night
Correct Answer: C
Rationale: Itching in the affected eye (C) may indicate infection or complications post-cataract surgery, requiring immediate intervention. Blurry vision (A) is expected initially, constipation (B) is unrelated, and sleeping elevated (D) is appropriate.
The nurse is talking with a client who has a new prescription for misoprostol to prevent gastric ulcers. Which of the following statements by the client would require follow-up?
- A. I will take this medication with meals and at bedtime.
- B. I plan to use a reliable form of birth control while taking this medication.
- C. I can take this medication with an antacid to prevent an upset stomach.
- D. I should notify my health care provider if I develop black, tarry stools while taking this medication.
Correct Answer: C
Rationale: Taking misoprostol with antacids (C) reduces its efficacy and requires follow-up. Taking with meals (A), using contraception (B), and reporting black stools (D) are correct.
The nurse has taught the parents of a 6-year-old client with nephrotic syndrome. Which of the following statements by the parents would require follow-up?
- A. I will encourage my child to play with other children.
- B. I will monitor my child's urine for protein every day.
- C. I will provide a healthy diet without added salt for my child.
- D. I will report swelling or rapid weight gain to the health care provider.
Correct Answer: A
Rationale: Encouraging play with others (A) may expose the child to infections, risky in nephrotic syndrome due to immunosuppression. Monitoring urine (B), low-salt diet (C), and reporting swelling (D) are correct.