Nokea
Which of the following statements should the nurse make?
- A. We can review some information to help you select a safe alternative practitioner.
- B. I there are therapies available to you, your provider will tell you about them.
- C. Feel free to try whatever therapies that fit within your personal belief system.
- D. I'm sure you can find alternative remedies through an online support group.
Correct Answer: A
Rationale: The correct answer is A because the nurse should offer to review information to assist the patient in selecting a safe alternative practitioner, showing support and guidance. Choice B is incorrect because it assumes the provider will inform the patient of therapies, not necessarily the nurse. Choice C is incorrect as it lacks professional guidance and may lead to unsafe choices. Choice D is incorrect as it suggests the patient can find remedies independently without professional advice.
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A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
- A. Document the client's behavior prior to being placed in seclusion,
- B. Assess the client's behavior once every hour
- C. Offer fluids every 2 hr.
- D. Discuss with the client his inappropriate behavior prior to seclusion
Correct Answer: A
Rationale: The correct answer is A: Document the client's behavior prior to being placed in seclusion. This is important for legal and clinical reasons as it provides a clear record of the client's behavior leading up to seclusion, ensuring transparency and accountability. Assessing behavior once every hour (choice B) may not be sufficient for monitoring the client's condition in seclusion. Offering fluids every 2 hours (choice C) is important for hydration but not directly related to seclusion. Discussing inappropriate behavior with the client (choice D) may escalate the situation and is not recommended in this scenario.
Which of the following guidelines should the nurse manager include?
- A. Remove the client's restraint every 4 hr
- B. Document the client's condition every 15 min.
- C. Request a PRN restraint prescription for clients who are aggressive.
- D. Attach the restraint to the bed's side rails.
Correct Answer: B
Rationale: The correct answer is B: Document the client's condition every 15 min. This guideline is crucial to monitor the client's well-being, detect any changes promptly, and ensure the effectiveness of the restraint. Removing the restraint every 4 hours (choice A) can compromise the client's safety and defeat the purpose of using restraints. Requesting a PRN restraint prescription for aggressive clients (choice C) may lead to overuse of restraints without proper assessment. Attaching restraints to the bed's side rails (choice D) can increase the risk of injury and is not recommended. Regular documentation is essential in ensuring the client's safety and well-being.
Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?
- A. Examine for leakage at the site of the procedure
- B. Compare the client's current weight with preprocedural weight
- C. Confirm that the client is able to urinate.
- D. Check the client's serum albumin levels.
Correct Answer: B
Rationale: The correct answer is B: Compare the client's current weight with preprocedural weight. This is the most appropriate action to evaluate the effectiveness of the procedure because changes in weight can indicate fluid retention or loss, which are common outcomes of many procedures. This comparison helps assess if the procedure had the desired effect on the client's fluid status.
Examine for leakage at the site of the procedure (A) is not the best action to evaluate the procedure's effectiveness as leakage may not always correlate with the overall success of the procedure. Confirming that the client is able to urinate (C) is important but may not directly indicate the effectiveness of the procedure. Checking the client's serum albumin levels (D) is relevant for assessing nutritional status but may not directly evaluate the procedure's effectiveness.
While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion(CPM) device. Which of the following actions should the nurse take first?
- A. Initiate a requisition for a replacement CPM device.
- B. Report the defect to the equipment maintenance staff.
- C. Remove the device from the room.
- D. Ensure the device inspection sticker is current.
Correct Answer: C
Rationale: The correct answer is C: Remove the device from the room. The fraying electrical cord poses a serious safety hazard, risking electrical shock or fire. The first step is to remove the device to prevent harm to the client or others. Initiating a requisition (A) or reporting to maintenance staff (B) can follow, but immediate removal is crucial. Ensuring the inspection sticker is current (D) is not the priority when there is a safety issue.
A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who is ambulatory and receiving oxygen
- B. A client who has a fracture and is in balance suspension traction
- C. A client who is bedridden and wears a hearing aid
- D. A client who uses a wheelchair and is confused
Correct Answer: A
Rationale: The correct answer is A: A client who is ambulatory and receiving oxygen should be evacuated first during a fire. This client has limited mobility due to the oxygen supply and is at high risk for respiratory compromise in a fire. Evacuating this client first ensures their safety and prevents potential harm.
Choice B: A client with a fracture in balance suspension traction requires stabilization but is not in immediate danger during a fire.
Choice C: A bedridden client wearing a hearing aid can be safely evacuated after the oxygen-dependent client.
Choice D: A confused client using a wheelchair may need assistance but is not at immediate risk like the oxygen-dependent client.