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.
You may also like to solve these questions
The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?
- A. Genital herpes and HIV
- B. Gonorrhea and chlamydia
- C. Human papillomavirus and syphilis
- D. Yeast and trichomoniasis
Correct Answer: B
Rationale: Gonorrhea and chlamydia (B) are bacterial infections that commonly cause pelvic inflammatory disease and infertility if untreated. Other options are less associated with these outcomes.
The nurse is reinforcing teaching for a client with suspected Cushing syndrome who has a 24-hour urine specimen. Which of the following information should the nurse reinforce? Select all that apply.
- A. An indwelling urinary catheter will be inserted for this test and your urine will be collected in an attached drainage bag.
- B. Discard your first void in the toilet and then record the start time of the urine collection so that the start time coincides with an empty bladder.
- C. Keep the collection container in the refrigerator or a cooled ice chest when it is not in use.
- D. Only daytime urine should be collected in the container because cortisol levels are higher in the morning.
- E. You will be given an opaque plastic container to collect your urine to protect it from light.
Correct Answer: B,C
Rationale: Discarding the first void and recording the start time (B) ensures accurate collection, and refrigerating the container (C) preserves the sample. Catheters (A) are not needed, all urine is collected (D is incorrect), and light protection (E) is unnecessary.
Discharge medications
Albuterol: 2 puffs every 4-6 hours as needed
Prednisone: 40 mg PO daily
Naproxen: 220 mg PO twice daily
Tiotropium: 1 capsule inhaled daily
A client with a history of degenerative arthritis is being discharged home following exacerbation of chronic obstructive pulmonary disease. After reviewing the discharge medications, the nurse should reinforce which of the following topics with the client? Select all that apply.
- A. Dryness of the mouth and throat may occur
- B. Ringing in the ears is an expected, transient side effect
- C. The albuterol canister should not be shaken before use
- D. The health care provider should be notified if stools are black and tarry
- E. Tiotropium capsules should not be swallowed
Correct Answer: A,D,E
Rationale: Dry mouth (A) is a side effect of COPD medications, black stools (D) may indicate GI bleeding, and tiotropium capsules are inhaled, not swallowed (E). Ringing in ears (B) is not expected, and albuterol should be shaken (C).
A client with chronic heart failure is being discharged home on furosemide and supplementary potassium chloride tablets. Which instructions related to the potassium supplement should the nurse reinforce to the client?
- A. A diet rich in protein and vitamin D will help with absorption.
- B. If the tablet is too large to swallow, crush and take it in applesauce or pudding.
- C. Potassium tablets should be taken on an empty stomach.
- D. Take it with plenty of water and sit upright for a period of time afterward.
Correct Answer: D
Rationale: Potassium chloride tablets should be taken with water and the client should remain upright to prevent esophageal irritation or ulceration (D). Protein and vitamin D (A) do not enhance absorption, crushing tablets (B) can cause irritation, and taking on an empty stomach (C) is unnecessary.
The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina?
- A. My pain is deep in my chest behind my breast bone.
- B. When I sit up the pain gets worse.
- C. As I take a deep breath the pain gets worse.
- D. The pain is right here in my stomach area.
Correct Answer: A
Rationale: My pain is deep in my chest behind my breast bone. This describes the typical substernal pain of acute angina.