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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.
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A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
- A. Ibuprofen
- B. Naproxen sodium
- C. Acetaminophen
- D. Aspirin
Correct Answer: C
Rationale: Rationale: Acetaminophen is the appropriate pain relief option to be taken concurrently with enoxaparin because it does not interfere with platelet aggregation or clotting factors, unlike other options. Ibuprofen, naproxen sodium, and aspirin are nonsteroidal anti-inflammatory drugs (NSAIDs) which can increase the risk of bleeding when taken with enoxaparin. Acetaminophen, on the other hand, does not have the same effect on platelet function, making it a safer choice for pain relief in patients taking enoxaparin.
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 findings require follow up? Select all that apply.
- A. WBC count
- B. Temperature
- C. Potassium level
- D. Breath sounds
- E. Blood pressure
Correct Answer: A,B,D,E
Rationale: These findings suggest infection and respiratory distress, requiring immediate follow-up.
Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Frequent nosebleeds
- C. Upper extremity hypotension
- D. Increased intracranial pressure
Correct Answer: A
Rationale: Coarctation causes weak or absent femoral pulses.
Which of the following information should the nurse include in the teaching?
- A. Take mineral oil at bedtime
- B. Decrease insoluble fiber intake
- C. Drink 1,5 L of fluids each day.
- D. Increase exercise activity.
Correct Answer: D
Rationale: The correct answer is D: Increase exercise activity. This is important for promoting regular bowel movements and overall gastrointestinal health. Exercise helps stimulate the digestive system and aids in relieving constipation. Taking mineral oil (choice A) can interfere with nutrient absorption and is not recommended for long-term use. Decreasing insoluble fiber intake (choice B) can worsen constipation as fiber helps promote bowel regularity. Drinking 1.5 L of fluids each day (choice C) is important for hydration but alone may not be sufficient to improve bowel function. Increasing exercise activity (choice D) is the most effective way to promote healthy digestion and prevent constipation.