Nokea
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 3 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
The nurse updates the nursing note with an environmental assessment for a 67-year-old female client with progressive multiple sclerosis. The nurse should first address the client's
- A. fatigue.
- B. sensation in the extremities.
- C. nutritional intake.
- D. environmental hazards.
Correct Answer: D
Rationale: Environmental hazards (e.g., furniture used for ambulation) pose an immediate fall risk, which is critical to address first for safety.
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The nurse is discussing infection control with a group of nursing students. Which indication would be appropriate for the nurse to use an alcohol-based sanitizer? Select all that apply.
- A. Immediately before touching a client
- B. After applying sterile gloves
- C. When changing linens for a client infected with Clostridium difficile
- D. After changing a diaper for an infant infected with norovirus
- E. After collecting vital signs on a client with human immunodeficiency virus (HIV)
Correct Answer: A,E
Rationale: Alcohol-based sanitizers are effective before touching a client and after non-soiled contact like vital signs for HIV. They are ineffective for C. difficile or norovirus, and hand washing is needed after applying gloves.
The nurse is teaching progressive relaxation techniques to a client. Which of the following statements by the client indicates that the teaching has been effective? Select all that apply.
- A. I will breathe in and out in rhythm.
- B. I expect my pulse to be faster afterwards.
- C. I expect to require less pain medication.
- D. I expect my muscles to feel less tense.
- E. I will report any increased sensitivity.
Correct Answer: A,C,D
Rationale: Rhythmic breathing, reduced pain medication needs, and muscle relaxation indicate effective relaxation. Faster pulse and increased sensitivity are incorrect expectations.
The nurse is caring for a child immediately postoperative following a left ear myringotomy. The nurse should position the child
- A. left lateral recumbent
- B. prone
- C. right lateral recumbent
- D. modified trendelenburg
Correct Answer: C
Rationale: Positioning the child on the right lateral recumbent side (operative ear up) post-myringotomy facilitates drainage from the left ear and prevents pressure on the surgical site. Left lateral recumbent or prone positions could obstruct drainage, and modified Trendelenburg is not indicated.
The nurse observes unlicensed assistive personnel (UAP) give a bed bath using 4% chlorhexidine (CHG) wipes. Which observation requires follow-up?
- A. The UAP uses one wipe for washing each major body part
- B. The UAP rinses the skin after bathing with the CHG solution
- C. The UAP washes the client's face with warm water and mild soap
- D. The UAP allows the CHG solution to dry on the client's skin
Correct Answer: B
Rationale: Rinsing CHG wipes removes their antimicrobial effect. Using separate wipes, washing the face separately, and allowing CHG to dry are correct.
One of the complications associated with the improper use of crutches is:
- A. Axillary nerve damage
- B. Solar plexus nerve damage
- C. Carpal tunnel syndrome
- D. Trigeminal nerve damage
Correct Answer: A
Rationale: Improper crutch use can compress the axillary nerve, causing nerve damage. Other options are unrelated to crutches.