Nokea
The nurse is performing a home safety assessment for an older adult. Which intervention would be appropriate for the nurse to recommend to reduce the client's risk of falling?
- A. Installation of non-slip mats in the kitchen
- B. Placement of furniture in the center of rooms
- C. Remove locks from doors
- D. Painting walls with bright colors
Correct Answer: A
Rationale: Non-slip mats reduce fall risk by improving traction. Furniture placement, door locks, and wall color do not directly address falls.
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A client is rushed to the emergency department after exposure to radioactive materials in a workplace accident. The client's supervisor phoned ahead and informed the charge nurse of the chemical with which the client came in contact. What should be the initial action of the nurse?
- A. Remove all the client's clothing and decontaminate the client.
- B. Ask the client what happened during the accident.
- C. Decontaminate the room where the client was staying.
- D. Save the clothing for analysis.
Correct Answer: A
Rationale: Removing clothing and decontaminating the client is the initial action to minimize radiation exposure.
The nurse is caring for a client in bilateral soft wrist restraints. The nurse should assess the client's? Select all that apply.
- A. behavioral status.
- B. skin integrity.
- C. bowel sounds.
- D. neurovascular status.
- E. need for restraint.
Correct Answer: A,B,D,E
Rationale: Behavioral status, skin integrity, neurovascular status, and need for restraint must be assessed to ensure safety and appropriateness of restraints. Bowel sounds are unrelated.
The nurse is preparing to administer a low-cleansing enema to a client. Which action by the nurse is appropriate during the administration of the enema?
- A. Administer the enema with the client in a supine position.
- B. Insert the enema tube 2 inches into the rectum.
- C. Use cold tap water for the enema solution.
- D. Hang the enema bag approximately 12 inches above the client's rectum.
Correct Answer: D
Rationale: Hanging the bag 12 inches above the rectum ensures proper flow. Supine position is incorrect, insertion is 3-4 inches, and cold water causes cramping.
The nurse is teaching a client about a vegetarian diet. Which of the following foods should the nurse recommend for this diet? Select all that apply.
- A. Legumes
- B. Almond butter
- C. Grilled chicken
- D. Apricots
- E. Baked fish
- F. Seafood salad
Correct Answer: A,B,D
Rationale: Vegetarian diets exclude meat, so legumes, almond butter, and apricots are suitable. Chicken, fish, and seafood are not vegetarian.
The nurse is caring for a client immediately following scleral buckling surgery for a retinal detachment of the right eye. Which of the following actions would be appropriate for the nurse to take?
- A. Place the client in a prone position
- B. Approach the client from the left side
- C. Instruct the client to perform deep breathing and coughing exercises
- D. Instruct client to avoid bending down
- E. Orientate the client to the environment
- F. Obtain a prescription for a stool softener
Correct Answer: B,D,E,F
Rationale: Post-scleral buckling surgery, the client’s positioning depends on the surgeon’s orders, but prone positioning is often avoided to prevent pressure on the eye. Approaching from the left side preserves the client’s intact visual field. Deep breathing and coughing may increase intraocular pressure and are typically avoided. Avoiding bending down prevents increased intraocular pressure. Orienting the client to the environment promotes safety due to potential vision changes. A stool softener prevents straining, which could increase intraocular pressure.