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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Which activity is appropriate to assign to a certified nursing assistant?
- A. Evaluate vital signs.
- B. Monitor tube feedings.
- C. Assist with activities of daily living (ADLs).
- D. Discuss discharge instructions.
Correct Answer: C
Rationale: Assisting with ADLs is within a CNA's scope, unlike evaluating vitals, monitoring feedings, or discussing instructions, which require nursing judgment.
The nurse is making a home visit to an adult who had a cataract extraction yesterday. Which observation indicates that the client needs more instruction?
- A. The client demonstrates putting eye drops in the conjunctival sac.
- B. The client has a patch on the affected eye.
- C. The client bends over to pick up the cat.
- D. The client is wearing slip-on shoes.
Correct Answer: C
Rationale: Bending over post-cataract surgery increases intraocular pressure, risking complications; this indicates a need for further instruction on activity restrictions.
The nurse has reinforced nutritional teaching on a client with gout who is placed on a low-purine diet. Which selection by the client would indicate a need for further teaching?
- A. Broccoli
- B. An orange
- C. Chocolate cake
- D. Fish
Correct Answer: D
Rationale: Fish should be avoided on a low-purine diet. Other foods to avoid include poultry, liver, lobster, oysters, peas, spinach, and oatmeal. Answers A, B, and C are all foods included on a low-purine diet, which makes them incorrect.
The nurse is reinforcing teaching to the caregiver of a child diagnosed with ringworm on the abdomen. Which statement by the caregiver indicates a need for further teaching?
- A. Handwashing is very important as ringworm can be spread among humans and pets.
- B. I must apply antifungal cream to all affected areas to eradicate ringworm from the body.
- C. My child has been infected by a worm and must be treated to rid it from the body.
- D. My child may be uncomfortable due to itching, but this is not a dangerous condition.
Correct Answer: C
Rationale: Ringworm is a fungal infection, not a parasitic worm (C), indicating a misunderstanding requiring further teaching. Handwashing (A), antifungal cream (B), and recognizing itching as non-dangerous (D) are correct, reflecting proper understanding.
The nurse is reviewing new medication prescriptions for a client with an acute exacerbation of asthma. Which of the following prescriptions should the nurse clarify?
- A. Albuterol 2.5 mg via nebulizer every 4 hours
- B. Potassium chloride 20 mEq (20 mmol) IV every 24 hours
- C. Enoxaparin 40 mg subcutaneously every 24 hours
- D. Methylprednisolone sodium succinate 20 mg IV every 6 hours
Correct Answer: B
Rationale: Potassium chloride (B) is not indicated for asthma exacerbation unless hypokalemia is documented, requiring clarification. Albuterol (A), methylprednisolone (D) treat asthma, and enoxaparin (C) may prevent thrombosis in immobile patients.