A client admitted with pneumonia and dementia has attempted several times to pull
out the IV and foley catheter. After trying other options, the nurse obtains a
prescription for bilateral soft wrist restraints. Which nursing action is most
appropriate?
a. Perform circulation checks to bilateral upper extremities each shift
b. Attach the ties of the restraints to the bed frame
c. Reevaluate the need for restraints and document weekly
d. Ensure the restraint prescription has been signed by the health care provider
within 72 hours - correct answer-B.
A client diagnosed with terminal cancer says to the nurse, "I'm going to die and I
wish my family would stop hoping for a cure! I get so angry when they carry on like
this. After all, I'm the one who's dying." Which response by the nurse is therapeutic?
a. Have you shared your feelings with your family?
b. I think we should talk about your anger with your family
c. You're feeling angry that your family continues to for hope for you to be cured?
d. You are probably very depressed, which is understandable with such a diagnosis -
correct answer-C.
A client is newly admitted with a diagnosis of left-sided heart failure. On assessment
of the
, client, which findings should a nurse expect?
A. Chest tightness and ascites
B. Dyspnea on exertion and ascites
C. Dyspnea on exertion and crackles
D. Neck vein distention and crackles - correct answer-C
A client placed in isolation for Tuberculosis asks the nurse why staff and visitors
must wear masks when in the patient's room. What response by the nurse indicates
understanding of TB isolation?
a. Masks are part of the isolation uniform that everyone must wear
b. The mask protects staff and visitors from contracting the disease and passing it to
others
c. The mask protects you from the germs staff and visitors carry in the room
d. Why are staff and visitors wearing masks in your room? They don't need to -
correct answer-B.
A client scheduled to take a subcutaneous anticoagulant at home says to the nurse,
"I'm not sure I will be able to take this medication at home." Which statement by the
nurse is MOST appropriate?
a. Maybe your spouse can give you your shots
b. You'll be fine once you get used to giving your own shots
c. What are your concerns about taking this medication at home?
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