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The nurse is teaching a client with a new diagnosis of epilepsy about self-care. Which of the following instructions should the nurse include?
- A. Avoid swimming or bathing alone.
- B. Take medications only when a seizure occurs.
- C. Drive a car as long as you feel alert.
- D. Consume alcohol in moderation to reduce stress.
Correct Answer: A
Rationale: avoiding swimming or bathing alone reduces the risk of injury during a seizure
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The nurse recognizes all of the following as type IV hypersensitivity reactions EXCEPT
- A. allergic contact dermatitis.
- B. Crohn's disease.
- C. graft versus host disease.
- D. penicillin allergy.
Correct Answer: D
Rationale: Type IV hypersensitivity is cell-mediated (e.g., contact dermatitis, Crohn’s, GVHD). Penicillin allergy is typically type I (IgE-mediated).
The nurse is caring for a client who is postoperative day 2 following a cholecystectomy. The client reports nausea and has not had a bowel movement since surgery. Which of the following actions should the nurse take FIRST?
- A. Administer an antiemetic as ordered.
- B. Encourage ambulation.
- C. Notify the physician.
- D. Assess the client’s abdomen for bowel sounds.
Correct Answer: D
Rationale: assessment of bowel sounds is the first step to determine if there is a postoperative ileus or other complication
The nurse is caring for a client with B-Thalassemia major. Which therapy is used to treat Thalassemia?
- A. IV fluids
- B. Frequent blood transfusions
- C. Oxygen therapy
- D. Iron therapy
Correct Answer: B
Rationale: Frequent transfusions manage severe anemia in B-Thalassemia major.
An RN delegates patient assignments to an LPN and nursing assistant. Later, the RN overhears a nursing assistant arguing with a patient regarding a late breakfast tray. The nursing assistant begins to raise his voice as the disagreement continues. The best action from the RN is
- A. call the nursing assistant out of the room and speak with him about the incident.
- B. apologize to the patient and assign another nursing assistant to that room.
- C. report the nursing assistant to the nursing manager for poor patient care.
- D. write an incident report and give a copy to the nursing assistant and nurse manager.
Correct Answer: A
Rationale: Addressing the nursing assistant privately de-escalates the situation, provides coaching, and maintains professionalism without immediate escalation.
A client in restraints is assigned to a newly graduated nurse. The nurse understands that which of the following are true regarding restraints? Select all that apply.
- A. Restraints can be chemical, mechanical, or physical.
- B. Children under 9 years of age have a 30-minute time limit in restraints.
- C. Bed rails are a form of restraint if used to prevent the client from leaving the bed.
- D. Restraints must be assessed every 2 hours for proper application and continued need.
- E. Once released, the client may be placed back in restraints for up to 24 hours if needed.
- F. Active listening, diversionary techniques, and reducing stimulation are alternatives to restraints.
Correct Answer: A, C, F
Rationale: Restraints include chemical, mechanical, or physical methods; bed rails are restraints if used to restrict movement; and non-restraint alternatives like active listening are preferred. Pediatric time limits and reassessment frequency vary by policy, and reapplication requires new orders.