Nokea
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
- A. The restraints/seclusion policies set forth by the institution.
- B. The patient’s competence.
- C. The patient’s voluntary/involuntary status.
- D. The patient’s nursing care plan.
Correct Answer: C
Rationale: The need for restraints is based on the patient’s behavior and safety risks, not their voluntary or involuntary admission status. Institutional policies, patient competence, and the care plan guide restraint use to ensure safety and compliance with legal and ethical standards.
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The nurse is planning care for a client with a diagnosis of paranoid schizophrenia. The nurse knows that questioning the client about his false ideas will
- A. cause him to defend the idea.
- B. help him clarify his thoughts.
- C. facilitate better communication.
- D. lead to a breakdown of the defense.
Correct Answer: A
Rationale: contraindicated; encourages patient to engage in further distortion of reality
The nurse is making a home visit for a client with an abdominal wound.
When irrigating the draining wound with a sterile saline solution, which of the following sequences would be MOST appropriate for the nurse to follow?
- A. Pour the solution, wash hands, and remove the soiled dressing.
- B. Wash hands, prepare the sterile field, and remove the soiled dressing.
- C. Prepare the sterile field, put on sterile gloves, and remove the soiled dressing.
- D. Remove the soiled dressing, flush the wound, and wash hands.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) hands should be washed first (2) correct-handwashing should be done prior to beginning any procedure, especially irrigating a wound (3) using sterile gloves to remove the dressing would contaminate them (4) hands should be washed first
The nursing team consists of an RN who has been practicing for 6 months, a LPN/LVN who has been practicing for 15 years, and a nursing assistant who has been caring for clients for 3 years. The RN should care for which of the following clients?
- A. A client 1-day postoperative after an internal fixation of a fractured left femur.
- B. A client receiving diltiazem (Cardizem) and phenytoin (Dilantin).
- C. A client who is to receive 2 units of packed cells prior to an upper endoscopy procedure.
- D. A client admitted yesterday with exhaustion and a diagnosis of acute bipolar disorder.
Correct Answer: C
Rationale: Blood transfusions require RN assessment and teaching due to risks like transfusion reactions. Options A, B, and D can be assigned to the nursing assistant (postop care) or LPN (medication administration, bipolar care), as they involve standard procedures.
A woman is in active labor with her first child when her membranes rupture. She voices a concern to the nurse that she is afraid of having a 'dry labor.' Which of the following responses by the nurse would be MOST appropriate?
- A. The amniotic fluid provides only minimal lubrication for the labor process.
- B. The amniotic sac may impede the progress of labor and is often ruptured artificially.
- C. Labor is only slightly more difficult with early rupture of the amniotic sac.
- D. Because there is limited amniotic fluid, additional fluids will be supplied.
Correct Answer: B
Rationale: Rupture of membranes can facilitate labor by removing the sac, which may impede progress, addressing the client’s 'dry labor' concern. Options A, C, and D are incorrect: amniotic fluid has multiple roles, labor difficulty is not significantly increased, and no fluids are added.
A 15-month old is admitted in sickle crisis. The parents ask why the child did not have any symptoms until now. What should be included in the nurse's response?
- A. The child was probably not exposed to it until recently.
- B. Antibodies from the mother are present for the first year of life.
- C. The symptoms do not manifest until the child is no longer breastfeeding.
- D. High fetal hemoglobin levels prevent symptoms for the first year of life.
Correct Answer: D
Rationale: High fetal hemoglobin (HbF) in infants inhibits sickling, delaying sickle cell anemia symptoms until HbF decreases around 6-12 months, replaced by adult hemoglobin.