Nokea
The nurse is visiting an older adult client with impaired vision. It would be necessary for the nurse to follow up if the client states which of the following? Select all that apply.
- A. I secured my throw rugs to the floor with tape.
- B. I switched to using an electric shaver instead of a razor.
- C. I usually sit in a recliner while I listen to the television.
- D. I use different shaped containers with lids to organize my medications.
- E. I use the upstairs bathroom instead of the one on the main floor.
Correct Answer: E
Rationale: Using an upstairs bathroom increases fall risk for a visually impaired client, requiring follow-up. Securing rugs, using an electric shaver, sitting in a recliner, and organizing medications are safe practices.
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A school nurse is discussing poison prevention and management with a group of parents. Which statement by parents would indicate a need for additional teaching?
- A. Containers of poisonous liquids need to be properly labeled.
- B. In the event gasoline is ingested by my child, vomiting should be induced.
- C. I may be able to give my child milk or water to dilute a corrosive poison while I rush them to the hospital.
- D. All poisonous materials should be securely stored away from children.
Correct Answer: B
Rationale: Inducing vomiting for gasoline ingestion is dangerous due to aspiration risk. Labeling, diluting corrosives (if advised), and secure storage are correct.
The nurse is caring for a client with a recently fractured left tibia who is grimacing and slightly diaphoretic. The nurse should initially
- A. Perform range of motion with the client's left leg.
- B. Obtain the client's temperature.
- C. Assess the client for pain.
- D. Administer prescribed oxycodone-acetaminophen.
Correct Answer: C
Rationale: Grimacing and diaphoresis suggest pain, which should be assessed first to guide interventions. Range of motion may worsen pain, temperature is secondary, and medication administration requires prior assessment.
The nurse is planning a staff development conference about ways to prevent the transmission of the hepatitis C virus to healthcare workers. It would be appropriate for the nurse to cover which topic?
- A. How to obtain the HCV vaccine
- B. How to dispose of sharps safely
- C. How to dispose of urine and feces for those with HCV
- D. Isolation precautions for individuals with HCV
Correct Answer: B
Rationale: Safe sharps disposal prevents needlestick injuries, a primary transmission route for HCV. No vaccine exists, and urine/feces disposal or isolation are less relevant.
The nurse has obtained a client's blood pressure. The nurse recognizes that which of the following factors may increase a client's blood pressure?
- A. Nicotine patch application
- B. Heat exhaustion
- C. Performing deep breathing exercises
- D. Hypothyroidism
Correct Answer: A
Rationale: Nicotine, a vasoconstrictor, increases blood pressure. Heat exhaustion, deep breathing, and hypothyroidism typically lower or do not affect BP acutely.
The nurse assesses a client who requires bilateral wrist restraints for agitation and hostility toward staff. When performing follow-up assessments, what data is necessary for the nurse to obtain? Select all that apply.
- A. previous restraint use
- B. skin integrity
- C. behavioral status
- D. vital signs
- E. urinary continence
Correct Answer: B,C,D
Rationale: Skin integrity, behavioral status, and vital signs must be assessed regularly to ensure safety, monitor for complications, and evaluate the ongoing need for restraints.