Nokea
Which action is most likely to ensure the safety of the nurse while making a home visit?
- A. Observe no evidence of weapons in the home during the visit
- B. Prior to the visit, review the client's record for any previous entries about violence
- C. Remain alert at all times and leave if cues suggest the home is not safe
- D. Carry a cell phone, pager and/or hand held alarm for emergencies
Correct Answer: C
Rationale: Remain alert at all times and leave if cues suggest the home is not safe. No person or equipment can guarantee nurses' safety, although the risk of violence can be minimized. Before making initial visits, review referral information carefully and have a plan to communicate with agency staff. Schedule appointments with clients. When driving into an area for the first time, note potential hazards. Observe surroundings when parking, walking to the client's door, making the visit, walking back to the car, and driving away. LISTEN to clients. If they tell you to leave, do so.
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A client has a cataract removed from the left eye. Which of the following is an important nursing intervention in the immediate postoperative period?
- A. Position the client on the right side with the head slightly elevated.
- B. Place the client on the left side to protect the eye.
- C. Perform sensory neurological checks every two hours.
- D. Maintain complete bedrest for the first 48 hours.
Correct Answer: A
Rationale: Positioning on the right side with head elevation prevents pressure on the surgical eye, reducing complications. Options B, C, and D are incorrect.
The nurse is teaching a client about the toxicity of digoxin. Which one of the following statements made by the client to the nurse indicates more teaching is needed?
- A. I may experience a loss of appetite.'
- B. I can expect occasional double vision.'
- C. Nausea and vomiting may last a few days.'
- D. I must report a bounding pulse of 62 immediately.'
Correct Answer: D
Rationale: Slow heart rate is related to increased cardiac output and an intended effect of digoxin. The ideal heart rate is above 60 BPM with digoxin. The client needs further teaching.
A 76-year-old man receiving isoniazid (INH) 200 mg every day for 6 months.
The nurse would be MOST concerned if the client made which of the following statements?
- A. I have blurred vision at times.'
- B. My legs and knees hurt.'
- C. My hands and feet tingle.'
- D. I think I had a migraine yesterday.'
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to Isoniazid. (1) infrequent side effect of the medication (2) not a side effect of the medication (3) correct-may cause peripheral neuropathy indicated by tingling, may also see nausea (4) not a side effect of the medication
When caring for a client with myasthenia gravis, an important nursing consideration would be to
- A. prevent accidents from falls as a result of vertigo.
- B. maintain fluid and electrolyte balance.
- C. control situations that could increase intracranial pressure and cerebral edema.
- D. assess muscle groups toward the end of the day.
Correct Answer: D
Rationale: client has increased muscle fatigue, needs more assistance toward end of day
The nurse observes a staff member not following the plan of care for a client with an antisocial personality disorder. The nurse should:
- A. confront the staff member immediately and say, 'You know that is not the treatment plan.'
- B. write an incident report to create a paper trail of the staff member's failure to follow the planned program.
- C. ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff.
- D. bring up the incident during the weekly conference so that this staff member is not assigned to work with antisocial persons again.
Correct Answer: C
Rationale: It is essential that the treatment program be followed exactly for clients with antisocial personality disorder because they are very manipulative and attempt to divide staff. However, confronting the staff member in front of the client enhances the division of staff.