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The nurse is supervising a newly hired nurse preparing a client for a computed tomography (CT) scan of the brain with intravenous (IV) contrast. Which action by the newly hired nurse requires follow-up?
- A. Encouraging fluids when the client returns from the scan.
- B. Confirming that the consent form is signed.
- C. Raising the side rails of the client's stretcher during transport.
- D. Canceling the CT scan if the client reports a shellfish allergy.
Correct Answer: D
Rationale: Canceling the CT scan for a shellfish allergy is premature; further evaluation is needed. Encouraging fluids, confirming consent, and raising side rails are appropriate.
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The nurse is teaching progressive relaxation techniques to a client. Which of the following statements by the client indicates that the teaching has been effective? Select all that apply.
- A. I will breathe in and out in rhythm.
- B. I expect my pulse to be faster afterwards.
- C. I expect to require less pain medication.
- D. I expect my muscles to feel less tense.
- E. I will report any increased sensitivity.
Correct Answer: A,C,D
Rationale: Rhythmic breathing, reduced pain medication needs, and muscle relaxation indicate effective relaxation. Faster pulse and increased sensitivity are incorrect expectations.
The nurse is interviewing a 25-year-old female client who recently experienced domestic violence. What is the rationale for excluding the family from the interview to ensure a safe and confidential environment? Select all that apply.
- A. Promote client autonomy
- B. Maintain family dynamics and support
- C. Maintains privacy and confidentiality
- D. Prevent potential intimidation or coercion
- E. Minimize the risk of retaliation
Correct Answer: A,C,D,E
Rationale: Excluding family promotes autonomy, privacy, and prevents intimidation or retaliation. Maintaining family dynamics is not a priority in this context.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 3 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
The nurse updates the nursing note with an environmental assessment for a 67-year-old female client with progressive multiple sclerosis. The nurse should first address the client's
- A. fatigue.
- B. sensation in the extremities.
- C. nutritional intake.
- D. environmental hazards.
Correct Answer: D
Rationale: Environmental hazards (e.g., furniture used for ambulation) pose an immediate fall risk, which is critical to address first for safety.
The nurse is observing the surgical aseptic technique of a nursing student. Which observation by the nurse requires follow-up?
- A. Spills sterile water onto the sterile field
- B. Uses sterile gloves to handle sterile supplies on a sterile field
- C. Has sterile gauze placed into the sterile field
- D. Keeps the sterile field above their waist
Correct Answer: A
Rationale: Spilling sterile water contaminates the sterile field, requiring follow-up. Other actions are consistent with aseptic technique.
You are educating a mother about the association between autism and the MMR vaccine. You know that the mother understands your instructions when she says:
- A. My child should not get the vaccine since it is known to cause autism.
- B. My child should get the individual immunizations for measles, mumps, and rubella since the individual vaccines do not cause autism.
- C. My child should get the MMR immunization since there is no evidence that it causes autism.
- D. My child should not get the immunization because it contains mercury.
Correct Answer: C
Rationale: Extensive research shows no link between MMR and autism, and MMR does not contain mercury. Individual vaccines are not standard, and avoiding vaccination is unsafe.