Nokea
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine, and the UAP is placing soft pillows along the side rails. What action should the nurse take?
- A. Ensure that the UAP has positioned the pillows effectively to protect the client.
- B. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
- C. Assume responsibility for placing the pillows while the UAP completes another task.
- D. Ask the UAP to use some of the pillows to prop the client in a side-lying position.
Correct Answer: B
Rationale: The nurse should instruct the UAP to pad the side rails with soft blankets instead of pillows. Placing pillows along the side rails could lead to suffocation during a seizure and would need to be removed promptly. Instructing the UAP to use soft blankets is safer as they can help prevent injury without posing a risk of suffocation. Ensuring effective placement of the pillows (Choice A) is not appropriate as pillows should not be used in this situation. Assuming responsibility for placing the pillows (Choice C) or propping the client in a side-lying position with pillows (Choice D) are both unsafe actions and could potentially harm the client.
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During the initial visit to a client with MS who is bed-bound and lifted by a hoist, which intervention is most important for the nurse to implement?
- A. Determine how the client is cared for when the caregiver is not present.
- B. Develop a client needs assessment and review it with the caregiver.
- C. Evaluate the caregiver's ability to care for the client's needs.
- D. Review with the caregiver the interventions provided each day.
Correct Answer: A
Rationale: During the initial visit, the most crucial intervention for the nurse is to determine how the client is cared for when the caregiver is not present. This is essential to ensure the client's safety and well-being, especially during times when the caregiver is not available. Option B is not the most important as it focuses on assessment rather than immediate safety concerns. Option C, while important, is secondary to ensuring continuous care. Option D is less critical during the initial visit compared to ensuring care continuity in the caregiver's absence.
A 10-year-old who has terminal brain cancer asks the nurse, 'What will happen to my body when I die?' How should the nurse respond?
- A. Your mother and father will be here soon. Talk to them about that.'
- B. Why do you want to know about what will happen to your body when you die?'
- C. The heart will stop beating and you will stop breathing.'
- D. Are you concerned about where your spirit will go?'
Correct Answer: C
Rationale: The correct response when a terminally ill child asks about what will happen to their body when they die is to provide a truthful and straightforward answer. Choice C, 'The heart will stop beating and you will stop breathing,' is the best response because it offers a simple and honest explanation without delving into spiritual or emotional aspects that may be confusing or distressing to the child. Choices A and D deflect the question and do not address the child's inquiry directly. Choice B, 'Why do you want to know about what will happen to your body when you die?' may come across as dismissive or evasive, rather than providing the clear information the child is seeking.
An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue taking her over-the-counter medications. Which medication poses the greatest threat to this client?
- A. Magnesium hydroxide (Maalox).
- B. Birth control pills.
- C. Cough syrup containing codeine.
- D. Cold medication containing alcohol.
Correct Answer: A
Rationale: The correct answer is A, Magnesium hydroxide (Maalox). In clients with chronic kidney disease (CKD), magnesium can accumulate to toxic levels as the kidneys are unable to excrete it efficiently. This can lead to hypermagnesemia, causing serious and potentially life-threatening complications. Birth control pills (choice B) are metabolized mainly by the liver and do not pose a significant threat to clients with CKD. Cough syrup containing codeine (choice C) should be used cautiously in CKD due to the risk of respiratory depression but does not pose as great a threat as magnesium accumulation. Cold medication containing alcohol (choice D) should be avoided in CKD but does not present the same level of danger as magnesium toxicity.
The nurse is caring for a client with chronic kidney disease (CKD). Which laboratory value should be reported to the healthcare provider immediately?
- A. Serum creatinine of 2.0 mg/dl
- B. Hemoglobin of 10 g/dl
- C. Potassium of 6.5 mEq/L
- D. Blood glucose of 150 mg/dl
Correct Answer: C
Rationale: The correct answer is C. A potassium level of 6.5 mEq/L is dangerously high, a condition known as hyperkalemia, and requires immediate intervention to prevent cardiac complications. Hyperkalemia can lead to life-threatening arrhythmias, making it crucial to notify the healthcare provider promptly. Choices A, B, and D do not indicate immediate life-threatening conditions. Elevated serum creatinine levels are expected in CKD, a hemoglobin level of 10 g/dl is within a reasonable range, and a blood glucose level of 150 mg/dl is not acutely concerning in this context.
A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed due to early morning stiffness. Which intervention should the nurse implement?
- A. Assign a UAP to assist the client with a warm shower early in the morning.
- B. Administer anti-inflammatory medication before the procedure.
- C. Encourage the client to perform range-of-motion exercises.
- D. Reschedule the procedure for later in the day.
Correct Answer: A
Rationale: A warm shower can help alleviate stiffness, allowing the client to be more comfortable and mobile before the procedure. This intervention promotes increased comfort and mobility, which may help the client proceed with the procedure later in the day. Administering anti-inflammatory medication (Choice B) may be helpful but may take time to be effective, while range-of-motion exercises (Choice C) may be challenging for the client due to stiffness. Rescheduling the procedure (Choice D) does not address the immediate need to alleviate stiffness.