Nokea
The nurse is performing rounding on clients in restraints. Which situation would require immediate intervention by the nurse?
- A. Client in a belt restraint in the semi-Fowler position
- B. Client in mitten restraints in the side-lying position
- C. Client in soft wrist restraints in the supine position
- D. Client in vest restraint in the high-Fowler position
Correct Answer: D
Rationale: A vest restraint in the high-Fowler position (D) poses a risk of strangulation or asphyxiation due to the restraint slipping upward, requiring immediate intervention. Belt restraint in semi-Fowler (A), mitten restraints in side-lying (B), and wrist restraints in supine (C) are safer positions, assuming proper application and monitoring.
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A client is to be discharged on enoxaparin (Lovenox) for the next two days. Which comment by the client indicates a need for further instruction?
- A. I will wash my hands before I prepare the injection.
- B. I will give the injection in my thigh.
- C. I will pinch the skin before I inject the medicine.
- D. I will not massage the area after the shot.
Correct Answer: B
Rationale: Enoxaparin is injected subcutaneously in the abdomen, not the thigh, indicating a need for further teaching.
The nurse is caring for a client with anorexia nervosa. Which of the following findings would be consistent with the condition? Select all that apply.
- A. Heat intolerance
- B. Has not menstruated in 3 months
- C. Avoids participation in physical activity
- D. Fine, downy hair on the face and back
- E. Decreased serum potassium level
- F. BMI of 16 kg/m²
Correct Answer: B,D,E,F
Rationale: Anorexia nervosa is characterized by severe weight loss and malnutrition, leading to specific clinical findings. Amenorrhea (B) results from hormonal imbalances due to low body fat. Lanugo (D), fine downy hair, develops as a compensatory mechanism for heat loss. Hypokalemia (E) occurs due to starvation or purging behaviors. A BMI of 16 kg/m² (F) indicates severe underweight status, consistent with anorexia. Heat intolerance (A) is more typical of hyperthyroidism, and avoiding physical activity (C) is incorrect as clients often engage in excessive exercise.
A client returns from the operating room after a right orchiectomy. For the immediate post-operative period the nursing priority would be to
- A. maintain fluid and electrolyte balance
- B. manage post-operative pain
- C. ambulate the client within 1 hour of surgery
- D. control bladder spasms
Correct Answer: B
Rationale: Due to the location of the incision, pain management is the priority. Bladder spasms are more related to prostate surgery.
An adult is prescribed lovastatin (Mevacor). The nurse should teach the client that while he is taking lovastatin (Mevacor), he must avoid:
- A. eating apples.
- B. drinking grapefruit juice.
- C. using aspirin.
- D. using ibuprofen.
Correct Answer: B
Rationale: Grapefruit juice inhibits CYP3A4, increasing lovastatin levels and risking toxicity, such as myopathy. Apples, aspirin, and ibuprofen do not have significant interactions with lovastatin.
The nurse is completing a client's intake and output record for the shift. How many mL should the nurse record as the client's net fluid balance for the shift?
Correct Answer: 890
Rationale: Without specific intake/output data, a general approach is assumed: net fluid balance is calculated as total intake (IV, oral, etc.) minus total output (urine, emesis, etc.). For example, if intake is 2000 mL and output is 1800 mL, the balance is 200 mL. The nurse must sum all recorded values accurately.