Nokea
Which of the following nursing interventions is MOST important when caring for a client who has just been placed in physical restraints?
- A. Prepare PRN dose of psychotropic medication.
- B. Check that the restraints have been applied correctly.
- C. Review hospital policy regarding duration of restraints.
- D. Monitor the client's needs for hydration and nutrition while restrained.
Correct Answer: B
Rationale: assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained
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A client is receiving a nitroglycerin infusion for unstable angina. What assessment would be a priority when monitoring the effects of this medication?
- A. Blood pressure
- B. Cardiac enzymes
- C. ECG analysis
- D. Respiratory rate
Correct Answer: A
Rationale: Since an effect of this drug is vasodilation, the client must be monitored for hypotension.
A 3-year-old with coarctation of the aorta is scheduled for corrective surgery. Which preoperative lab result should be reported to the physician?
- A. HCT 48%
- B. WBC 14,000
- C. Platelet count 200,000
- D. RBC 5.3
Correct Answer: B
Rationale: A WBC of 14,000 suggests possible infection, which should be reported before surgery, so B is correct. HCT 48% , platelet count 200,000 , and RBC 5.3 are within normal ranges.
An adult who has chronic obstructive pulmonary disease (COPD) is receiving oxygen at home via nasal cannula. In addition to instructing the client and his family about not smoking when oxygen is in use, what should the nurse plan to include in the teaching?
- A. If the prescribed liter flow does not relieve his difficulty breathing, increase the liter flow by up to 2 L/min every four hours.
- B. Try not to shuffle across the carpeted floor.
- C. Clean the nasal cannula with alcohol several times a day.
- D. Increase the oxygen flow rate if you develop shortness of breath.
Correct Answer: B
Rationale: Shuffling across carpet generates static electricity, risking sparks near oxygen, which is a fire hazard. Adjusting oxygen flow without medical orders or cleaning with alcohol (instead of soap and water) is unsafe.
In providing care to a 14 year-old adolescent with scoliosis, which of the following will be most difficult for this client?
- A. Compliance with treatment regimens
- B. Looking different from their peers
- C. Lacking independence in activities
- D. Reliance on family for their social support
Correct Answer: B
Rationale: Looking different from their peers. Conformity is critical at age 14, and visible differences due to scoliosis treatment can be challenging.
Following hip replacement surgery, an elderly client is ordered to begin ambulation with a walker.
Which of the following statements by the nurse is BEST?
- A. Sit in a low chair for ease in getting up to use the walker.
- B. Make sure rubber caps are in place on all four legs of the walker.
- C. You will begin weight-bearing on the affected hip soon.
- D. Practice tying your own shoes before you begin ambulating.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (2) correct-intact rubber caps should be present on walker legs to prevent accidents (3) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (4) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks