Nokea
The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply.
- A. Guide the client to the floor and gently cradle the head
- B. Insert a tongue blade to prevent client from swallowing the tongue
- C. Move objects that may cause injury away from the client
- D. Physically restrain the client to prevent injury
- E. Place the client in left lateral position
- F. Remain with the client, observe, and record the seizure activity
Correct Answer: A, C, E, F
Rationale: Guiding to the floor (A), clearing objects (C), positioning laterally (E), and observing (F) ensure safety. Tongue blades (B) are dangerous, and restraining (D) increases injury risk.
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A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? Select all that apply.
- A. Maintain short fingernails to minimize excoriating the skin
- B. Take a bath or shower in hot water to alleviate itching sensations
- C. Take prescribed cholestyramine 1 hour after other medications
- D. Use a moisturizing cream on unbroken skin daily
- E. Wear wool gloves and tight stockings to avoid scratching
Correct Answer: A, C, D
Rationale: Short fingernails (A), cholestyramine timing (C), and moisturizing cream (D) reduce itching and protect skin. Hot water (B) worsens itching, and wool gloves/tight stockings (E) may irritate skin.
The nurse is caring for a client who had a chest tube inserted and attached to portable water seal drainage two days ago. There is no bubbling in the water seal chamber. What should the nurse assess initially?
- A. Observe the wound for excess drainage
- B. Check the system for air leaks
- C. Auscultate the lungs
- D. See if the suction is turned on
Correct Answer: C
Rationale: No bubbling may indicate lung reexpansion or system issues; auscultating lungs assesses reexpansion or complications like pneumothorax. Other assessments are secondary.
A 13-month-old child is admitted to the pediatric unit with diarrhea and vomiting. The mother tells the nurse that she is worried because her son does not yet walk. She says her other children walked at eight and nine months and asks what could be wrong with this child. How should the nurse respond?
- A. All babies are different. It is not abnormal that the baby is not yet walking.'
- B. The baby should be walking. I'll let the doctor know he is behind developmentally.'
- C. Your son is probably enjoying being the baby and is not eager to grow up and walk.'
- D. Walking requires complex coordination. Your son is probably just a little slow to develop this. Don't worry.'
Correct Answer: A
Rationale: Walking typically occurs between 9-18 months; at 13 months, not walking is within normal variation, reassuring the mother without dismissing concerns.
The nurse reinforces teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug?
- A. Need for an eye examination
- B. Need for sunblock
- C. Risk for infection
- D. Risk for kidney injury
Correct Answer: C
Rationale: Methotrexate suppresses the immune system, significantly increasing the risk for infection (C). This is a critical teaching point to ensure the client takes precautions. Eye exams (A), sunblock (B), and kidney injury (D) are less directly associated with methotrexate's primary risks.
The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?
- A. Place pillows under the knees
- B. Use elastic stockings continuously
- C. Encourage range of motion and ambulation
- D. Massage the legs twice daily
Correct Answer: C
Rationale: Encourage range of motion and ambulation. Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk due to other factors.