Nokea
A nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurse include?
- A. Document the client's condition every 15 minutes.
- B. Attach the restraint straps to the side rails of the bed.
- C. Use a square knot to secure the restraint.
- D. Ensure there is at least a 2-inch gap between the restraint and the client's body.
Correct Answer: A
Rationale: The correct answer is A: Document the client's condition every 15 minutes. This guideline is crucial for monitoring the client's status, detecting any changes promptly, and ensuring their safety. Documenting every 15 minutes allows for timely intervention and assessment.
Choice B is incorrect because attaching restraint straps to the side rails can lead to entrapment and harm.
Choice C is incorrect as a square knot is not recommended for securing restraints due to the risk of difficulty in quick release during emergencies.
Choice D is incorrect as a 2-inch gap between the restraint and the client's body can increase the risk of injury or self-removal.
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A nurse is providing discharge teaching to a client following a total gastrectomy.
The nurse should instruct the client about which of the following medications?
- A. Ranitidine
- B. Vitamin B
- C. Metoclopramide
- D. Vitamin K
Correct Answer: B
Rationale: The correct answer is B: Vitamin B. The nurse should instruct the client about Vitamin B because it plays a crucial role in various bodily functions such as energy production, nerve function, and red blood cell formation. Deficiency in Vitamin B can lead to various health issues. Ranitidine, Metoclopramide, and Vitamin K are specific medications that are not typically instructed by nurses unless prescribed by a healthcare provider for specific conditions. Vitamin K is essential for blood clotting, but its education is usually provided by healthcare providers for specific cases.
A nurse in the emergency department is caring for a client who is actively bleeding from a stab wound to the thigh.
Which action should the nurse take?
- A. Apply direct pressure to the wound with thick dressing material.
- B. Elevate the affected leg above heart level and apply light dressing.
- C. Apply a tourniquet immediately above the wound site.
- D. Apply ice packs to the wound to slow the bleeding.
Correct Answer: A
Rationale: The correct answer is A. Applying direct pressure to the wound with thick dressing material is the most appropriate action to control bleeding. It helps to compress the blood vessels, slowing down the bleeding. Elevating the leg (choice B) may not be enough to stop severe bleeding. Applying a tourniquet (choice C) should only be done as a last resort for life-threatening bleeding as it can lead to tissue damage. Applying ice packs (choice D) constricts blood vessels, potentially trapping harmful substances in the wound. It is crucial to address the immediate bleeding before considering other actions.
A nurse is caring for a client who has an implanted venous access port.
Which of the following should the nurse use to assess the port?
- A. An Angio catheter
- B. A butterfly needle
- C. A noncoring needle
- D. A 25-gauge needle
Correct Answer: C
Rationale: The correct answer is C: A noncoring needle. To assess a port, a noncoring needle should be used because it is specifically designed for accessing ports without damaging the septum. Using an Angio catheter (A) may be too large and cause damage, a butterfly needle (B) is not suitable for accessing ports, and a 25-gauge needle (D) may be too small or not specifically designed for port access. Noncoring needles are the standard choice for accessing ports due to their design that minimizes trauma and ensures proper function.
The nurse is continuing to care for the client.
History and Physical
Day 1, 0900:
A 52-year-old client brought to emergency department by adult child. Client is alert and oriented
to person and time but does not know where they are. No history of substance use according to
client's adult child. Client exhibits constant movements and poor concentration. Hair and
clothing are unclean. Appears to be listening to unseen others. Skin turgor poor.
The nurse is providing teaching about lithium to the client and client's adult child. Select the 3 statements the nurse should include.
- A. Blurred vision is an expected adverse effect pf this medication
- B. It will take at least a week before this medication reaches a therapeutic level.
- C. This medication can cause nausea and drowsiness.
- D. You will be placed on a low sodium diet while taking this medication.
- E. This medication can cause weight gain.
Correct Answer: B,C,E
Rationale: Blurred vision is not typical; lithium takes time to reach therapeutic levels, causes nausea/drowsiness, and often leads to weight gain. A low-sodium diet is contraindicated due to risk of toxicity.
A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI(11) is intact when the client performs which of the following actions?
- A. Shrugs his shoulders
- B. Smiles symmetrically
- C. Closes his eyes tightly
- D. Identifies a familiar scent
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the accessory nerve, controls the movement of the trapezius and sternocleidomastoid muscles, which are responsible for shoulder shrugging. By asking the client to shrug his shoulders, the nurse can assess the integrity of cranial nerve XI.
Choices B, C, and D are incorrect because they are associated with other cranial nerves. Smiling symmetrically is controlled by cranial nerve VII (facial nerve), closing eyes tightly is controlled by cranial nerve V (trigeminal nerve), and identifying a familiar scent is related to cranial nerve I (olfactory nerve).