The nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should:
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Solution
Answer B is correct. The best action for the nurse to take is to explore the interaction with the nursing assistant. This will allow for clarification of the situation. Changing the assignment in answer A might need to be done, but talking to the nursing assistant is the first step. Answer C is incorrect because discussing the incident with the family is not necessary at this time; it might cause more problems. Answer C is not a first step, even though initiating a group session might be a plan for the future.
The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse?
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Solution
Answer B is correct. The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it should be determined by the charge nurse. Answers A, C, and D are incorrect because notifying the police is overreacting at this time, and monitoring or ignoring the situation is an inadequate response.
Which client can best be assigned to the newly licensed practical nurse?
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Solution
Answer D is correct. The best client to assign to the newly licensed nurse is the most stable client; in this case, it is the client with diverticulitis. The client receiving chemotherapy and the client with a coronary bypass both need nurses experienced in these areas, so answers A and B are incorrect. Answer D is incorrect because the client with a transurethral prostatectomy might bleed, so this client should be assigned to a nurse who knows how much bleeding is within normal limits.
The physician has ordered that the client’s medication be administered intrathecally. The nurse is aware that medications will be administered by which method?
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Solution
Answer D is correct. Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metastases, the client with chronic pain, or the client with cerebrospinal infections. Answers A, B, and C are incorrect because intravenous, rectal, and intramuscular injections are entirely different procedures.
The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
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Solution
Answer B is correct. Montgomery straps are used to secure dressings that require frequent dressing changes because the client with a cholecystectomy usually has a large amount of drainage on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape. This client is not at higher risk of evisceration than other clients, so answer A is incorrect. Montgomery straps are not used to secure the drains, so answer C is incorrect. Sutures or clips are used to secure the wound of the client who has had gallbladder surgery, so answer D is incorrect.
A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?
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Solution
Answer B is correct. The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a Levine tube should be anticipated. Answers A and C are incorrect because blood pressures are not required every 15 minutes, and cardiac monitoring might be needed, but this is individualized to the client. Answer D is incorrect because there are no dressings to change on this client.
The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention?
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Solution
Answer B is correct. Oils can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin. Answer A is incorrect because bathing twice a day is too frequent and can cause more dryness. Answer C is incorrect because powder is also drying. Rinsing with hot water, as stated in answer D, dries out the skin as well.
The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough?
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Solution
Answer A is correct. If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer had included a mask, gloves, and a gown, all would be appropriate, but in this case, only one item is listed; therefore, answers B and C are incorrect. Shoe covers are not necessary, so answer D is incorrect.
A client visits the clinic after the death of a parent. Which statement made by the client’s sister signifies abnormal grieving?
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Solution
Answer D is correct. Abnormal grieving is exhibited by a lack of feeling sad; if the client’s sister appears not to grieve, it might be abnormal grieving. This family member might be suppressing feelings of grief. Answers A, B, and C are all normal expressions of grief and, therefore, incorrect.
The nurse is obtaining a history of an 80-year-old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance?
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Solution
Answer B is correct. Frequent use of laxatives can lead to diarrhea and electrolyte loss. Answers A, C, and D are not of particular significance in this case and, therefore, are incorrect.