Nokea
The nurse is caring for clients in a hospital setting. Which observations made by the nurse require intervention? Select all that apply.
- A. The client's infusion pump is noted to have a cut in the center of the cord.
- B. The client's bed is in the high position after a nursing assistant left the room.
- C. The client's battery-operated CD player does not have an agency inspection tag.
- D. The client's bed exit alarm is beeping, and another nurse just left the room.
- E. The client's bedside table is placed in front of the chair where the client is sitting.
Correct Answer: A,B,D
Rationale: A: A cut cord poses an electrical shock risk. B: A high bed increases fall risk. D: A beeping bed exit alarm indicates a potential fall risk requiring immediate response.
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While the nurse is administering medications to a client, the client states 'I do not want to take that medicine today.' Which of the following responses by the nurse would be best?
- A. That's OK, its all right to skip your medication now and then.'
- B. I will have to call your doctor and report this.'
- C. Is there a reason why you don't want to take your medicine?'
- D. Do you understand the consequences of refusing your prescribed treatment?'
Correct Answer: C
Rationale: When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.
The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (ALS). Which of these pieces of equipment is the priority for the client to have access to in the home?
- A. A wheelchair
- B. A hospital bed with trapeze
- C. A communication board
- D. A suction machine
Correct Answer: C
Rationale: In late-stage ALS, clients often lose the ability to speak due to muscle weakness. A communication board is critical to ensure the client can express needs and maintain communication.
A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that
- A. such fantasies can gratify unconscious wishes or prepare for anticipated future events
- B. detaching or dissociating in this way postpones painful feelings
- C. converting or transferring a mental conflict to a physical symptom can lead to conflict within the partnership
- D. isolating the feelings in this way reduces conflict within the client and with others
Correct Answer: A
Rationale: such fantasies can gratify unconscious wishes or prepare for anticipated future events. Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratify unconscious wishes.
The client makes the following statements to the home health nurse. Which statement requires the nurse to intervene immediately?
- A. "I can't lift pans from the back burners, but I can manage just fine by using the front burners of my stove."
- B. "I almost fell down the stairs, so I bought myself a pair of slippers with nonskid soles."
- C. "The grass near the sidewalk will be dead because my son insists on putting salt on the icy sidewalk."
- D. "My home is less costly to heat when I use my gas oven with the oven door open to heat just my living areas."
Correct Answer: D
Rationale: Using a gas oven for heating risks carbon monoxide poisoning, requiring immediate intervention to prevent a life-threatening situation.
A nurse has been ordered to administer Morphine to a patient. Which of the following effects is unrelated to Morphine's effects on the patient?
- A. Depressed function of the CNS
- B. Increased blood flow
- C. Decreased venous capacity
- D. Pain relief
Correct Answer: C
Rationale: Venous capacity increases with morphine use, not decreases, as it causes vasodilation.