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A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery.
Which of the following actions should the nurse include in the plan of care?
- A. Observe for bruising of the skin
- B. Provide a diet low in protein
- C. Monitor v/s every hour for the first 4 hr.
- D. Administer medications intramuscularly
Correct Answer: A
Rationale: The correct answer is A: Observe for bruising of the skin. This is important in assessing for potential complications such as bleeding disorders, which may indicate a need for further intervention. Providing a diet low in protein (B) is not relevant to the scenario unless specified. Monitoring vital signs every hour for the first 4 hours (C) may not be necessary unless there are specific concerns. Administering medications intramuscularly (D) is not indicated without further context.
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A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile.
Which of the following infection control precautions should the nurse take?
- A. Remove the protective gown while in the client's room.
- B. Place the client in a private room with contact precautions.
- C. Perform hand hygiene using an alcohol-based sanitizer.
- D. Wear an N95 mask when entering the client's room.
Correct Answer: B
Rationale: The correct answer is B: Place the client in a private room with contact precautions. This is the most appropriate infection control measure for preventing the spread of infections. Placing the client in a private room helps to prevent transmission to other individuals. Contact precautions involve using gloves and gowns when in contact with the client or their environment, further reducing the risk of transmission. Choices A, C, and D are incorrect. Removing the protective gown while in the client's room (A) increases the risk of contamination. Hand hygiene using an alcohol-based sanitizer (C) is important but alone is not sufficient for contact precautions. Wearing an N95 mask when entering the client's room (D) is not necessary unless the client has airborne precautions.
A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management.
Which type of insulin should the nurse anticipate administering?
- A. Glargine insulin.
- B. Regular insulin.
- C. NPH insulin.
- D. Insulin aspart.
Correct Answer: A
Rationale: The correct answer is A: Glargine insulin because it is a long-acting insulin with a duration of action of up to 24 hours, providing a basal level of insulin throughout the day. It is typically administered once daily at the same time each day to maintain stable blood glucose levels. Regular insulin (B) is short-acting and is usually given before meals. NPH insulin (C) is intermediate-acting and has a peak action of 4-12 hours. Insulin aspart (D) is a rapid-acting insulin used for mealtime coverage. In this scenario, the nurse should anticipate administering Glargine insulin for its long-acting, basal properties.
A nurse is teaching a client about a variety of stress management techniques.
Which of the following instructions by the nurse is appropriate?
- A. Tighten your muscles before relaxing them when using muscle relaxation techniques
- B. Avoid deep breathing exercises, as they can increase stress.
- C. Focus on multiple thoughts at once to distract yourself from stress.
- D. Keep your emotions bottled up to maintain control over stress.
Correct Answer: A
Rationale: The correct answer is A because tightening muscles before relaxing them helps to enhance the effectiveness of muscle relaxation techniques by creating a greater sense of contrast between tension and relaxation. This sequence promotes deeper relaxation and can help reduce stress more effectively. Choice B is incorrect as deep breathing exercises are commonly used to reduce stress and promote relaxation. Choice C is incorrect as focusing on multiple thoughts at once can increase stress and overwhelm the individual. Choice D is incorrect as bottling up emotions can lead to increased stress and negatively impact mental health.
A nurse is providing teaching about home safety to an adult child of an older adult client who is postoperative following knee replacement surgery.
Which of the following instructions should the nurse include?
- A. Mark the edges of the doorway to the house with tape.
- B. Remove loose rugs from the home to prevent falls.
- C. Place soft cushions on all chairs to reduce discomfort.
- D. Install bright overhead lighting in the bedroom only.
Correct Answer: B
Rationale: The correct answer is B: Remove loose rugs from the home to prevent falls. This instruction is crucial in preventing falls, especially for elderly individuals who may have balance issues. Loose rugs are a common tripping hazard and removing them can significantly reduce the risk of falls. Marking the edges of the doorway with tape (A) may not be effective in preventing falls as it does not address the actual hazards. Placing soft cushions on all chairs (C) does not directly address fall prevention and may not be suitable for all individuals. Installing bright overhead lighting in the bedroom only (D) is important for visibility but does not address other fall risks in the home.
A charge nurse is observing A newly licensed nurse provide care for a client who is post-operative. The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not void.
Which of the following torts should the charge nurse identify as having occurred?
- A. Assault
- B. Battery
- C. False imprisonment
- D. Negligence
Correct Answer: A
Rationale: The charge nurse should identify assault as having occurred. Assault is the intentional act that causes a person to fear they will be harmed. In this case, if a healthcare provider threatens a patient with a procedure without their consent, it constitutes assault. Battery, on the other hand, is the intentional harmful or offensive touching of a person without consent. False imprisonment involves restraining a person against their will, which is not described in the scenario. Negligence refers to a failure to exercise reasonable care, and it does not apply here as the situation involves intentional actions.