Nokea
The nurse observes a certified nursing assistant (CNA) moving a client up in bed. Which action by the nursing assistant indicates a need for more instruction in how to move a client?
- A. Using a pull sheet
- B. Asking another nursing assistant to help
- C. Lowering the head of the bed
- D. Pulling the client by the shoulders
Correct Answer: D
Rationale: Pulling by the shoulders risks injury to the client's skin and joints. Using a pull sheet, getting help, and lowering the bed are correct techniques to ensure safety.
You may also like to solve these questions
The nurse is preparing to administer ear drops to a 5-year-old client. Which of the following actions should the nurse take?
- A. Pull the client's pinna upward and back.
- B. Help the client sit upright with the chin tilted down.
- C. Touch the dropper to the entrance of the ear canal.
- D. Remove the medication from the refrigerator just before use.
Correct Answer: A
Rationale: Pulling the pinna upward and back (A) straightens the ear canal in children over 3. Sitting with chin down (B), touching the canal (C), or cold drops (D) are incorrect.
The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most appropriate?
- A. The client has acute urinary retention
- B. The client is confused and incontinent
- C. The client is elderly and at risk for falls
- D. The client is receiving intravenous diuretics
Correct Answer: A
Rationale: Acute urinary retention (A) is a medical indication for catheterization. Confusion/incontinence (B), fall risk (C), and diuretics (D) are not sufficient justifications.
A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include to reinforce prior teaching? Select all that apply.
- A. Apply patch to the upper arm or chest
- B. Fold used patches in half with sticky sides together before discarding
- C. Remove patch if dizziness occurs when getting up
- D. Rotate sites each time a new patch is applied
- E. Shave hair before applying patch
Correct Answer: A, B, D
Rationale: Applying to upper arm/chest (A), folding patches (B), and rotating sites (D) ensure safe use. Removing for dizziness (C) requires medical consultation, and shaving (E) can irritate skin.
The nurse administers subcutaneous insulin lispro at 0730 to a client as prescribed and the client consumes breakfast 30 minutes later. At what time is the client at highest risk for experiencing insulin-related hypoglycemia?
- A. 830
- B. 1100
- C. 1330
- D. 1500
Correct Answer: B
Rationale: Insulin lispro peaks 1-2 hours after administration, so 1100 (B), about 3.5 hours post-injection, is the highest risk time for hypoglycemia.
In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?
- A. White patches
- B. Green drainage
- C. Reddened tissue
- D. Eschar development
Correct Answer: C
Rationale: Reddened tissue. Redness indicates granulation tissue formation, a sign of healing.