Nokea
The nurse should perform which intervention when a client is restrained?
- A. Remove the restraints and provide skin care hourly.
- B. Document the condition of the client's skin every 3 hours.
- C. Assess the restraint every 30 minutes.
- D. Tie the restraint to the side rails.
Correct Answer: C
Rationale: The minimum standard is to visually assess the restraint every 30 minutes. Documentation is typically performed per a checklist or flow sheet. The ends of the restraint are tied to a part of the bed that allows for position changes without unfastening them.
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When a drug is listed as Category X and prescribed to women of child-bearing age/capacity, the nurse and the interdisciplinary team should counsel the client that:
- A. Pregnancy tests might be unreliable while taking the drug.
- B. She must use a reliable form of birth control.
- C. She should not take the Category X drug on days she has intercourse.
- D. She must follow up with an endocrinologist.
Correct Answer: B
Rationale: Category X drugs have many practice limitations when prescribed and dispensed to women. For example, the prescription is valid for only seven days, and if not filled, it expires. The FDA provides a pregnancy-prevention program for clients taking Isotretinoin (Accutane). Prior to prescribing a Category X drug, a pregnancy test should be performed.
A 6-year-old is admitted to the ED after ingesting oxycodone tablets that had been prescribed for the parent. The parent provides the prescription bottle that originally contained 15 tablets of oxycodone 5 mg. The parent stated taking 3 tablets. There are 9 tablets remaining in the bottle. If the child ingested the missing tablets, how many mg of oxycodone did the child ingest?
Correct Answer: 15
Rationale: 15 - 3 = 12; 12 - 9 = 3; 3 tablets x 5 mg = 15 mg. The child ingested 15 mg of oxycodone.
The client that the nurse is ambulating becomes dizzy and feels faint. Place the nurse's actions in the correct order to prevent the client from falling.
- A. Support and ease the client to the floor by sliding the client down the forward leg
- B. Call for help
- C. Bend at the knees and pull the client toward the forward leg
- D. Assess the client for injuries
- E. Protect the client's head from hitting objects on the floor
- F. Assume a broad stance with the stronger leg somewhat behind the other leg
Correct Answer: B,F,C,A,E,D
Rationale: The sequence ensures safety: call for help (B), establish a stable stance (F), lower the client safely (C, A), protect the head (E), and assess injuries (D).
The client with DM is receiving care in the home for a foot ulcer. The home health nurse documents the narrative note illustrated. Which problem should be the nurse's priority on the return visit?
- A. Impaired skin integrity related to left foot ulcer
- B. Potential for injury related to improper footwear
- C. Potential altered nutrition: less than body requirements related to nausea
- D. Ineffective therapeutic regimen management related to not taking medications as prescribed
Correct Answer: B
Rationale: Improper footwear increases the risk of injury or falls, which is critical for a diabetic client with reduced foot sensation and a healing ulcer.
Which of these comments by a client would indicate the need for further teaching regarding safety with warfarin (Coumadin)?
- A. I need to stop the medication 3 days before my dental appointment.'
- B. I will report any bruising or bleeding to my doctor.'
- C. I plan to eat more green leafy vegetables this week.'
- D. I will check with my doctor before taking any new medication.'
Correct Answer: C
Rationale: Green leafy vegetables are high in vitamin K, which can counteract the anticoagulant effects of warfarin, requiring further teaching to ensure safe dietary practices.