Nokea
When a client is prescribed seizure precautions, which interventions should the nurse include in the plan of care? Select all that apply.
- A. Having suction equipment readily available
- B. Keeping all the lights on in the room at night
- C. Keeping a padded tongue blade at the bedside
- D. Assisting the client to ambulate in the hallway
- E. Monitoring the client closely while showering
- F. Locking the client's bed in its lowest position
Correct Answer: A,D,E,F
Rationale: Suction equipment should be readily available to remove accumulated secretions after the seizure. The client should be accompanied during activities such as bathing and walking so that assistance is readily available and injury is minimized if a seizure begins. The bed is maintained in a low position for safety. A quiet, restful environment is provided as part of seizure precautions. This includes undisturbed times for sleep, while using a night-light (not all lights) for safety. A padded tongue blade is not kept at the bedside because nothing is inserted into the client's mouth during the seizure. Agency procedures regarding seizure precautions are always followed.
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A usually reliable interpreter called by the nurse to help communicate with a mother of a child who does not speak English and has brought her child in for a routine visit has yet to arrive in the clinic. The nurse has paged the interpreter several times. Which of the following should the nurse do next?
- A. Continue with the examination.
- B. Reschedule the infant's appointment for later in the week.
- C. Ask the mother to stay longer in the hope that the interpreter arrives.
- D. Page the interpreter one more time.
Correct Answer: B
Rationale: Rescheduling ensures effective communication with the interpreter, avoiding potential misunderstandings during the visit.
The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minutes, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action?
- A. Notify the physician.
- B. Administer a sedative.
- C. Try to elicit a positive Homan's sign.
- D. Increase the flow rate of intravenous fluids.
Correct Answer: A
Rationale: These symptoms suggest a possible pulmonary embolism, a life-threatening complication of DVT, requiring immediate physician notification.
A client with a history of osteoporosis is prescribed alendronate (Fosamax). The nurse should instruct the client to take the medication:
- A. At bedtime with a snack.
- B. First thing in the morning with water.
- C. With meals to enhance absorption.
- D. With milk to reduce stomach irritation.
Correct Answer: A
Rationale: Alendronate should be taken first thing in the morning with water, on an empty stomach, to maximize absorption and minimize esophageal irritation.
A client at 12 weeks' gestation tells the nurse that she is a vegetarian and eats 'lots of rice.' To help meet the client's need for protein during pregnancy, the nurse suggests that the client combine the rice with which of the following?
- A. Beans.
- B. Soy milk.
- C. Yogurt.
- D. Corn.
Correct Answer: A
Rationale: Combining rice with beans provides a complete protein, meeting the increased protein needs during pregnancy.
Which type of anemia is diagnosed with a Schilling test?
- A. Aplastic
- B. Pernicious
- C. Megaloblastic
- D. Iron deficiency
Correct Answer: B
Rationale: The Schilling test is used to determine the cause of vitamin B12 deficiency, a potential precursor to pernicious anemia. This test involves the use of a small oral dose of radioactive B12 and a large nonradioactive intramuscular dose. A 24-hour urine specimen is then collected to measure the amount of radioactivity in the urine, and thus radioactive B12. This test is not helpful in diagnosing aplastic, megaloblastic, or iron-deficiency anemia.