Nokea
The nurse is planning a staff development conference about restraints. Which of the following information should the nurse include? Select all that apply.
- A. Mittens that are untethered are not considered a restraint.
- B. Elbow restraints may allow a client to remove abdominal or urinary medical devices.
- C. Belt restraints should be applied over a client's clothing garments.
- D. The client should be positioned prone while soft-wrist restraints are applied.
- E. Continuous verbal aggression with staff is an indication to apply restraints.
Correct Answer: A,C
Rationale: Untethered mittens are not restraints, and belt restraints should be applied over clothing to prevent skin irritation. Elbow restraints restrict arm movement, prone positioning is unsafe, and verbal aggression alone does not justify restraints.
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The nurse is observing a newly hired nurse insert a nasogastric tube (NGT). Which action by the newly hired nurse requires follow-up?
- A. Advances the tube during the client's inspiration.
- B. Hands the client a cup of water and straw.
- C. Positions the client's head-of-bed at 90 degrees.
- D. Washes the client's bridge of nose with soap and water.
Correct Answer: A
Rationale: Advancing an NGT during inspiration increases the risk of tracheal placement. Providing water, elevating the bed to 90 degrees, and cleaning the nose are appropriate actions.
A nurse is caring for a client who has complete immobility and is bedbound. Which of the following complications should the nurse monitor for? Select all that apply.
- A. Peripheral neuropathy
- B. Increased peristalsis leading to diarrhea
- C. Joint contractures
- D. Increased bone density
- E. Peripheral edema
- F. Pneumonia
Correct Answer: C,E,F
Rationale: Immobility causes contractures, edema, and pneumonia due to reduced mobility and lung expansion. Neuropathy and increased peristalsis are unrelated, and bone density decreases.
The nurse is teaching a continuing education course on communicable diseases. Which of the following statements should the nurse make about diphtheria? Select all that apply.
- A. The organism that causes this condition is Corynebacterium diphtheriae.
- B. Vaccination is available starting at two months of age.
- C. Transmission of the cutaneous diphtheria is via direct contact with the infected person.
- D. Airborne precautions are required for individuals with pharyngeal diphtheria.
- E. Diphtheria is caused by a virus and is highly contagious.
Correct Answer: A,B,C,D
Rationale: Diphtheria is caused by Corynebacterium diphtheriae, vaccinated via DTaP at two months, cutaneous form spreads by contact, and pharyngeal diphtheria requires airborne precautions. It is bacterial, not viral.
The nurse is caring for a client who has been physically violent towards staff. The nurse prepares to restrain the client using
- A. soft wrist restraints.
- B. mitten restraints.
- C. elbow restraints.
- D. waist belt restraint.
Correct Answer: A
Rationale: Soft wrist restraints are appropriate for preventing harm in violent clients while allowing some movement. Other options are less suitable.
The nurse is discussing mass casualties with a group of nursing students. Which statement by the student would indicate effective understanding? Select all that apply.
- A. Mass casualties are events that overwhelm local medical capabilities.
- B. When a mass casualty occurs, there is a need to increase the staff at the hospital.
- C. Many local agencies will collaborate to handle a mass casualty situation.
- D. An example of a mass casualty event is a fight between visitors in the intensive care unit.
- E. Staff preferences for client assignments should prioritize over client needs.
Correct Answer: A,B,C
Rationale: Mass casualties overwhelm resources, require more staff, and involve multi-agency collaboration. A visitor fight is not a mass casualty, and client needs take priority.