Ati rn fundamentals 2023
Total Questions : 58
Showing 25 questions, Sign in for moreA charge nurse is observing a staff nurse performing wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?
Explanation
Choice A Reason:
Refrigerating the solution before irrigation is not recommended. The solution should be at room temperature to avoid causing discomfort or vasoconstriction, which can impede the healing process.
Choice B Reason:
Administering an analgesic medication 5 minutes before starting irrigation is correct. This action helps manage the client’s pain during the procedure, ensuring comfort and compliance.
Choice C Reason:
Using one pair of gloves for both dressing removal and irrigation is incorrect. The nurse should use separate pairs of gloves to prevent cross-contamination and maintain aseptic technique.
Choice D Reason:
Using a syringe with a catheter for wound irrigation is correct practice. This method allows for controlled and directed irrigation, ensuring the wound is properly cleaned.
A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?
Explanation
Choice A Reason:
Moving quickly to a position in front of the client is not recommended. This action could result in both the nurse and the client falling, potentially causing injury to both parties.
Choice B Reason:
Remaining upright as the client falls toward them is incorrect. This action does not provide adequate support or control, increasing the risk of injury to the client.
Choice C Reason:
Allowing the client to slide down their outstretched leg is the correct action. This technique helps control the fall and minimizes the risk of injury by providing a controlled descent to the floor.
Choice D Reason:
Placing their arms around the client to prevent the fall is not advisable. This action can lead to both the nurse and the client falling, which could result in injuries.
A nurse is caring for a client who is 6 hours postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?
Explanation
Choice A Reason
Allowing the client to hear running water while attempting to void can sometimes help stimulate urination through the power of suggestion. This method is non-invasive and can be effective for some patients. However, it may not be sufficient for a client who is 6 hours postoperative and experiencing significant difficulty voiding. In such cases, more direct intervention may be necessary to prevent complications like bladder distension or urinary retention.
Choice B Reason
Encouraging fluid intake up to 1,000 mL daily is generally good advice for maintaining hydration and promoting urinary function. However, in the immediate postoperative period, especially within the first 6 hours, the focus should be on addressing the acute issue of urinary retention. Increasing fluid intake alone may not resolve the problem and could potentially exacerbate bladder distension if the client is unable to void.
Choice C Reason
Providing the client a bedpan while lying supine is a practical approach to assist with urination, especially if the client is unable to get out of bed. However, the supine position is not the most conducive for voiding, as it can make it more difficult for the bladder to empty completely. This method might not be effective for a client experiencing significant difficulty voiding postoperatively.
Choice D Reason
Inserting an indwelling urinary catheter and connecting it to gravity drainage is the most appropriate action for a client who is 6 hours postoperative and having difficulty voiding. This intervention directly addresses the issue of urinary retention by ensuring that the bladder is emptied, thereby preventing complications such as bladder distension, urinary tract infections, and potential kidney damage. It is a standard practice in postoperative care when less invasive methods are ineffective.
A nurse enters a client’s room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?
Explanation
Choice A Reason
Lifting the client to the bed with assistance is not recommended during a seizure. Moving the client can increase the risk of injury to both the client and the nurse. The primary focus should be on ensuring the client’s safety by preventing injury from nearby objects and allowing the seizure to run its course.
Choice B Reason
Turning the client onto their back is not advisable during a seizure. This position can increase the risk of airway obstruction and aspiration. Instead, the client should be turned onto their side to maintain an open airway and allow any secretions to drain from the mouth, reducing the risk of aspiration.
Choice C Reason
Clearing the nearby area of furniture is the most appropriate action. This helps to prevent the client from injuring themselves on hard or sharp objects during the seizure. Ensuring a safe environment is a key priority in managing a seizure, as it minimizes the risk of physical harm.
Choice D Reason
Placing a tongue depressor in the client’s mouth is an outdated and dangerous practice. It can cause injury to the client’s teeth, mouth, or airway. There is also a risk of the client biting down and breaking the depressor, leading to choking hazards. Modern seizure management guidelines strongly advise against placing any objects in the client’s mouth during a seizure.
A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?
Explanation
Choice A Reason
Eyelashes that curl slightly outward are a normal finding in an eye assessment. This natural curl helps protect the eyes from debris and sweat, and it also aids in the distribution of tears across the eye surface. Eyelashes that curl outward are typical and expected in a healthy individual.
Choice B Reason
Corneas with an opaque appearance are not a normal finding. The cornea should be clear and transparent, allowing light to pass through to the retina. An opaque cornea can indicate various conditions such as corneal edema, scarring, or infection. Therefore, this finding would be abnormal and warrant further investigation.
Choice C Reason
Eyelids that blink involuntarily 30 to 35 times per minute are not within the normal range. The average blink rate for a healthy adult is approximately 15 to 20 times per minute. A significantly higher blink rate could indicate an underlying condition such as dry eye syndrome, blepharospasm, or other neurological issues.
Choice D Reason
Pupils that are 8 to 9 mm in diameter are abnormally large. The normal pupil size ranges from 2 to 4 mm in bright light and 4 to 8 mm in dim light. Pupils that are consistently larger than this range could indicate a condition such as mydriasis, which can be caused by various factors including medications, trauma, or neurological disorders.
A nurse is caring for a postoperative client. Which of the following findings indicate the client may be actively bleeding?
Explanation
Choice A: Bounding Pulses
Bounding pulses are typically associated with increased cardiac output or high blood pressure, rather than active bleeding. In the context of postoperative care, bounding pulses might indicate fluid overload or other cardiovascular issues, but they are not a primary sign of active bleeding.
Choice B: Restlessness
Restlessness is a common sign of hypovolemia, which can occur due to active bleeding. When a patient is losing blood, their body may respond with anxiety or restlessness as a result of decreased oxygen delivery to tissues and organs. This is a compensatory mechanism to maintain perfusion. Restlessness, along with other signs such as tachycardia and hypotension, can indicate significant blood loss and the need for immediate intervention.
Choice C: Warm Skin
Warm skin is generally not associated with active bleeding. In fact, patients who are actively bleeding may present with cool, clammy skin due to peripheral vasoconstriction as the body attempts to maintain core temperature and blood flow to vital organs. Warm skin might be observed in other conditions, such as fever or inflammation, but it is not a typical sign of active bleeding.
Choice D: Brisk Capillary Refill
Brisk capillary refill, which is a capillary refill time of less than 2 seconds, indicates good peripheral perfusion and is not a sign of active bleeding. In contrast, a delayed capillary refill time (greater than 2 seconds) can be a sign of poor perfusion, which might occur in the case of significant blood loss. Therefore, brisk capillary refill is not indicative of active bleeding.
A nurse is teaching an older adult client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of the teaching?
Explanation
Choice A: I will walk three times per week.
Walking is a weight-bearing exercise, which is crucial for maintaining bone density and reducing the risk of osteoporosis. Regular physical activity, especially weight-bearing exercises like walking, helps stimulate bone formation and slows down bone loss. The National Osteoporosis Foundation recommends at least 30 minutes of weight-bearing exercise on most days of the week to help prevent osteoporosis.
Choice B: I will avoid exposure to the sun.
Avoiding sun exposure is not advisable for reducing the risk of osteoporosis. Sunlight is a natural source of vitamin D, which is essential for calcium absorption and bone health. While excessive sun exposure can be harmful, moderate exposure helps the body produce sufficient vitamin D. Therefore, avoiding sun exposure entirely can lead to vitamin D deficiency, increasing the risk of osteoporosis.
Choice C: I will take 250 milligrams of calcium once per day.
The recommended daily intake of calcium for older adults is significantly higher than 250 milligrams. For adults aged 51 and older, the National Institutes of Health recommends 1,200 milligrams of calcium per day. Adequate calcium intake is vital for maintaining bone health and preventing osteoporosis. Therefore, taking only 250 milligrams of calcium per day is insufficient to meet the body’s needs.
Choice D: I will decrease my intake of dairy products.
Dairy products are a primary source of calcium, which is essential for bone health. Reducing the intake of dairy products can lead to inadequate calcium intake, increasing the risk of osteoporosis. Instead, older adults should ensure they consume enough dairy or other calcium-rich foods to meet their daily calcium requirements.
A nurse is caring for a client who has a new diagnosis of insulin-dependent diabetes mellitus. The client states, “I am concerned about being able to monitor my blood glucose regularly due to my busy schedule.” Which of the following responses should the nurse make?
Explanation
Choice A Reason
“You should be fine as long as you check your blood glucose before eating.” This response is not ideal because it oversimplifies the complexity of managing insulin-dependent diabetes. Blood glucose monitoring should be done at various times throughout the day, including before meals, after meals, and possibly before bedtime, to ensure proper management and avoid complications. Limiting checks to just before meals may not provide a comprehensive picture of the client’s glucose levels.
Choice B Reason
“We can discuss several scheduling options for monitoring your blood glucose.” This response is the most appropriate as it acknowledges the client’s concern and offers a collaborative approach to finding a solution. It allows the nurse to tailor the blood glucose monitoring schedule to fit the client’s busy lifestyle, ensuring better adherence and management of diabetes. This approach also empowers the client by involving them in their care plan.
Choice C Reason
“You should reorganize your schedule around your blood glucose monitoring.” While it is important for the client to prioritize their health, this response may come across as dismissive of the client’s busy schedule. It does not offer practical solutions or flexibility, which are crucial for long-term adherence to diabetes management. A more supportive and collaborative approach would be more effective.
Choice D Reason
“Your provider will set up a schedule for when you should monitor your blood glucose.” This response places the responsibility solely on the healthcare provider and does not address the client’s immediate concern about fitting blood glucose monitoring into their busy schedule. While the provider’s input is important, the nurse should also offer immediate support and practical solutions. Collaborative planning is key to effective diabetes management.
A nurse is preparing to lift a box of personal items off the floor in a client’s room. Which of the following actions should the nurse take to help prevent injury when lifting the box?
Explanation
Choice A Reason
Bending at the waist to pick up the box is not recommended as it can put excessive strain on the lower back. Proper lifting techniques involve bending at the knees and hips, not the waist, to use the stronger muscles of the legs and reduce the risk of back injury. This method helps maintain the natural curve of the spine and distributes the load more evenly.
Choice B Reason
When lifting the box, keeping it close to the body is the most appropriate action. This technique reduces the lever arm distance, thereby decreasing the strain on the back muscles and spine. Holding the load close to the body ensures better control and stability, making it easier to lift and carry the box safely.
Choice C Reason
Keeping the feet close together when lifting a box is not advisable. A wide stance, with feet shoulder-width apart, provides better balance and stability. This position allows for a more secure lift and reduces the risk of losing balance or straining muscles during the lifting process.
Choice D Reason
Relaxing the abdominal muscles to prevent straining the back is incorrect. Engaging the core muscles, including the abdominals, provides additional support to the spine and helps maintain proper posture during lifting. Tightening the abdominal muscles can help stabilize the torso and reduce the risk of back injury.
A nurse is planning care for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take?
Explanation
Choice A: Seat the client in a chair for 30 minutes prior to applying the stockings.
Seating the client in a chair for 30 minutes before applying the stockings is not necessary. In fact, it is recommended to apply antiembolic stockings while the client is in a supine position to prevent blood from pooling in the legs. This ensures that the stockings fit properly and provide the intended compression to promote venous return.
Choice B: Measure the length of the client’s leg from the heel to the gluteal fold.
Measuring the length of the client’s leg from the heel to the gluteal fold is essential for ensuring the correct fit of knee-length antiembolic stockings. Proper measurement helps in selecting the right size, which is crucial for the stockings to be effective in preventing deep vein thrombosis (DVT) by promoting blood circulation. Incorrectly sized stockings may either be too tight, causing discomfort and impaired circulation, or too loose, failing to provide adequate compression.
Choice C: Instruct the client to point their toes while applying the stockings.
Instructing the client to point their toes while applying the stockings is not a standard practice. Instead, the nurse should gather the stocking material and gently roll it over the foot and up the leg, ensuring it is evenly distributed and free of wrinkles. This method helps in applying the stockings smoothly and effectively without causing discomfort or improper fit.
Choice D: Roll the top of the client’s stockings down to just below the knee.
Rolling the top of the stockings down to just below the knee is incorrect and can lead to a tourniquet effect, which can impede blood flow and increase the risk of DVT. The stockings should be applied smoothly and should extend to their full length without being rolled down to ensure proper compression and effectiveness.
A nurse is providing teaching to a client about colorectal cancer prevention guidelines. Which of the following recommendations should the nurse include?
Explanation
Choice A: Have a fecal occult blood test every 2 years.
The recommendation for fecal occult blood tests (FOBT) is typically to have them annually, not every 2 years. Regular screening is crucial for early detection of colorectal cancer. The American Cancer Society suggests that people aged 45 and older should have an FOBT every year. This test helps detect hidden blood in the stool, which can be an early sign of cancer.
Choice B: Limit intake of dietary fiber.
Dietary fiber is actually beneficial in reducing the risk of colorectal cancer. High-fiber diets, rich in fruits, vegetables, and whole grains, are associated with a lower risk of developing colorectal cancer. Fiber helps in maintaining a healthy digestive system and can aid in the prevention of cancer by promoting regular bowel movements and reducing the time that potential carcinogens stay in the colon.
Choice C: Reduce intake of red meats.
Reducing the intake of red meats is a well-supported recommendation for lowering the risk of colorectal cancer. Studies have shown that high consumption of red and processed meats is linked to an increased risk of colorectal cancer. Reducing the intake of these meats and opting for healthier protein sources like fish, poultry, and plant-based proteins can help lower this risk.
Choice D: Have a colonoscopy every 3 years.
The standard recommendation for colonoscopy screening is every 10 years for individuals at average risk, starting at age 45. More frequent colonoscopies, such as every 3 years, are generally reserved for those with higher risk factors, such as a family history of colorectal cancer or the presence of polyps. Regular colonoscopy screenings are vital for detecting and removing polyps before they can develop into cancer.
A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority?
Explanation
Choice A Reason
Increased heart rate during physical activity can be a common finding in clients who have been on bed rest for an extended period. This is due to deconditioning of the cardiovascular system. While it is important to monitor and address, it is not the most immediate concern compared to other potential complications.
Choice B Reason
Loss of appetite is another common issue in clients who have been on prolonged bed rest. It can lead to nutritional deficiencies and weight loss, which are significant concerns. However, it is not as urgent as other findings that might indicate more acute complications.
Choice C Reason
Left lower extremity tenderness is the most critical finding and should be identified as the priority. This symptom can indicate deep vein thrombosis (DVT), a serious condition that can lead to life-threatening complications such as pulmonary embolism if not promptly addressed. DVT is a common risk for clients who have been immobile for extended periods, making it a top priority for immediate
intervention.
Choice D Reason
Musculoskeletal weakness is expected in clients who have been on bed rest for several weeks. It results from muscle atrophy and deconditioning. While it is an important issue to address through rehabilitation and physical therapy, it does not pose an immediate threat to the client’s life compared to the risk of DVT.
A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the following statements by the client indicates an understanding of the use of the supplements?
Explanation
Choice A: I use garlic for my menopausal symptoms.
Garlic is not typically used for menopausal symptoms. Common herbal supplements for menopause include black cohosh, red clover, and evening primrose oil. These herbs are known to help alleviate symptoms such as hot flashes and night sweats. Garlic, on the other hand, is more commonly associated with cardiovascular benefits, such as lowering blood pressure and cholesterol levels.
Choice B: I use ginger when I get car sick.
Ginger is well-known for its effectiveness in treating nausea and motion sickness. Studies have shown that ginger can help reduce symptoms of motion sickness, such as dizziness, vomiting, and cold sweats. It works by stabilizing digestive function and maintaining consistent blood pressure, which helps alleviate nausea. Therefore, using ginger for car sickness is a correct and effective use of the supplement.
Choice C: I take ginkgo biloba for a headache.
Ginkgo biloba is not typically used for headaches. It is more commonly used to improve cognitive function and circulation. While some studies suggest that ginkgo biloba may help reduce the frequency and severity of migraines due to its antioxidant properties, it is not a primary treatment for headaches. Other supplements, such as feverfew and butterbur, are more commonly recommended for headache relief.
Choice D: I take echinacea to control my cholesterol.
Echinacea is primarily used to boost the immune system and help fight infections, such as the common cold. There is no substantial evidence to support the use of echinacea for controlling cholesterol levels For cholesterol management, supplements like omega-3 fatty acids, plant sterols, and soluble fiber are more effective.
A nurse discovers an overlooked prescription for a type and crossmatch of a client who is scheduled for surgery. After notifying the laboratory, which of the following actions should the nurse take?
Explanation
Choice A Reason
Preparing an incident report is an important step in documenting the oversight and ensuring that similar errors are prevented in the future. However, it is not the immediate priority when addressing the current situation. The primary focus should be on ensuring the client’s safety and the timely completion of the necessary preoperative procedures.
Choice B Reason
Canceling the client’s surgery is a drastic measure that should only be considered if there is no other way to ensure the client’s safety. Before taking such a step, the nurse should explore all other options to rectify the situation, such as notifying the operative team and the provider. This allows for a collaborative approach to determine the best course of action.
Choice C Reason
Notifying the operative team of the omission is the most appropriate action. This ensures that all relevant healthcare providers are aware of the situation and can take the necessary steps to address it. The operative team can then decide whether to proceed with the surgery as planned or to delay it until the type and crossmatch are completed. This collaborative approach prioritizes the client’s safety and ensures that all necessary precautions are taken.
Choice D Reason
Giving the client another blood consent form to sign is not directly related to addressing the overlooked prescription for a type and crossmatch. While obtaining informed consent is crucial, it does not resolve the immediate issue of ensuring that the client has the correct blood type and crossmatch completed before surgery. The focus should be on rectifying the oversight and ensuring that all preoperative requirements are met.
A nurse is preparing to assess a client’s carotid arteries. Which of the following actions should the nurse plan to take?
Explanation
Choice A Reason
Placing the client in a high-Fowler’s position during the assessment is not necessary for assessing the carotid arteries. While this position can be useful for other assessments, it is not specifically required for carotid artery evaluation. The client can be in a seated or supine position with the head slightly elevated.
Choice B Reason
Auscultating each carotid artery with the bell of the stethoscope is the most appropriate action. This technique allows the nurse to listen for bruits, which are abnormal sounds indicating turbulent blood flow due to partial obstruction or narrowing of the artery. Using the bell of the stethoscope is crucial because it is better suited for detecting low-pitched vascular sounds.
Choice C Reason
Palpating the carotid arteries simultaneously is not recommended. Doing so can significantly reduce blood flow to the brain, potentially causing dizziness or fainting. Instead, each carotid artery should be palpated individually to assess the amplitude and contour of the pulse without compromising circulation.
Choice D Reason
Massaging the carotid artery while assessing the client is inappropriate and potentially dangerous. Massaging the carotid artery can stimulate the carotid sinus, leading to a reflex drop in heart rate and blood pressure, which can cause syncope (fainting). This action should be avoided during assessment.
A nurse is planning care for a client who has a seizure disorder. Which of the following actions should the nurse include in the client’s plan of care?
Explanation
Choice A: Have a padded tongue blade available at the client’s bedside.
Having a padded tongue blade available is not recommended for seizure management. Inserting any object into a patient’s mouth during a seizure can cause injury to the teeth, gums, or jaw1. Current guidelines advise against placing anything in the mouth of a person having a seizure. Instead, focus on ensuring the patient’s safety by turning them on their side to maintain an open airway and prevent aspiration.
Choice B: Keep the four side rails down when the client is in bed.
Keeping the side rails down is not advisable for a client with a seizure disorder. To prevent injury during a seizure, it is important to keep the side rails up and padded. This helps prevent the client from falling out of bed and sustaining injuries. Additionally, the bed should be kept in its lowest position to minimize the risk of injury from falls.
Choice C: Keep suction equipment available in the client’s room.
Keeping suction equipment available is crucial for managing a client with a seizure disorder. During a seizure, there is a risk of aspiration due to excessive salivation or vomiting. Having suction equipment readily available allows the nurse to quickly clear the client’s airway, reducing the risk of aspiration and ensuring the client can breathe properly.
Choice D: Have wire cutters available at the client’s bedside.
Wire cutters are not typically necessary for managing a seizure disorder. They are sometimes mentioned in the context of clients with Vagus Nerve Stimulators (VNS), where the wire cutters might be used in an emergency to cut the VNS wire. However, this is a rare situation and not a standard precaution for all clients with seizure disorders4.
A nurse is caring for a client who has a traumatic brain injury and needs to relearn how to use eating utensils. The nurse should refer the client to which of the following members of the interprofessional team?
Explanation
Choice A: Physical therapist
Physical therapists primarily focus on improving a patient’s physical function, mobility, and strength. They work on activities such as walking, balance, and coordination1. While they play a crucial role in the rehabilitation of clients with traumatic brain injuries, their expertise is not specifically centered on activities of daily living (ADLs) like using eating utensils.
Choice B: Occupational therapist
Occupational therapists specialize in helping clients regain the ability to perform ADLs, which include tasks such as eating, dressing, and bathing. They use therapeutic techniques to improve fine motor skills, coordination, and cognitive function, which are essential for relearning how to use eating utensils. Their goal is to enhance the client’s independence and quality of life by enabling them to perform everyday activities.
Choice C: Speech-language pathologist
Speech-language pathologists focus on communication disorders and swallowing difficulties. They work with clients to improve speech, language, and cognitive-communication skills. While they are essential for addressing issues related to speech and swallowing, they do not typically focus on the motor skills required for using eating utensils.
Choice D: Social worker
Social workers provide support and resources to help clients and their families cope with the emotional, social, and financial aspects of a traumatic brain injury. They assist with discharge planning, accessing community resources, and providing counseling. However, they do not provide direct rehabilitation services related to the use of eating utensils.
A home health nurse is providing teaching about home safety to an older adult client. Which of the following examples of home safety should the nurse include in the teaching?
Explanation
Choice A Reason:
Using extension cords to prevent overloading circuits is not a recommended safety practice. Extension cords can pose tripping hazards and may not be designed to handle the electrical load of multiple devices, which can lead to overheating and potential fire risks.
Choice B Reason:
Obtaining a raised toilet seat for the bathroom is a practical safety measure for older adults. It helps reduce the risk of falls by making it easier for individuals with limited mobility to sit down and stand up from the toilet. This modification can significantly enhance bathroom safety.
Choice C Reason:
Covering slippery stairs with an area rug is not advisable. Area rugs can slip and create additional hazards. Instead, using non-slip treads or securing the rug with non-slip backing is a safer alternative.
Choice D Reason:
Securing loose wires under carpeting is not recommended. This practice can create a fire hazard and make it difficult to access the wires if needed. It’s better to use cable management solutions that keep wires organized and out of the way without hiding them under carpeting.
A nurse is preparing to transfer a client to the radiology department using a wheelchair. Which of the following actions should the nurse take?
Explanation
Choice A Reason:
Leaving a transfer belt in place until the client returns from radiology is not recommended. The transfer belt is used to assist in moving the client safely, but it should be removed once the client is securely seated in the wheelchair to prevent discomfort or potential injury.
Choice B Reason:
Positioning the client so their weight is shifted forward is not a standard practice for transferring a client to a wheelchair. Proper positioning involves ensuring the client is seated comfortably and securely, with their weight evenly distributed to prevent falls or injuries.
Choice C Reason:
Lowering the footplates before transferring the client from the bed is incorrect. The footplates should be raised to allow the client to safely transfer from the bed to the wheelchair without tripping or getting their feet caught.
Choice D Reason:
Backing the wheelchair into the elevator is the correct action. This ensures that the client enters the elevator facing forward, which is safer and more comfortable for the client. It also allows the nurse to maintain better control of the wheelchair during the transition.
A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?
Explanation
Choice A Reason:
The four-point alternating gait is used when a client can bear weight on both legs. This gait provides maximum stability and is often used for clients with poor balance or coordination. It involves moving one crutch forward, followed by the opposite leg, then the other crutch, and finally the other leg. Since the client can only bear weight on one leg, this gait is not appropriate.
Choice B Reason:
The two-point alternating gait is also used when a client can bear weight on both legs. It is faster than the four-point gait and involves moving one crutch and the opposite leg simultaneously, followed by the other crutch and the opposite leg. This gait requires partial weight-bearing on both legs, making it unsuitable for a client who can only bear weight on one leg.
Choice C Reason:
The three-point gait is specifically designed for clients who can only bear weight on one leg. In this gait, both crutches are moved forward together, followed by the weight-bearing leg. The non-weight-bearing leg is then swung through. This gait provides the necessary support and stability for clients with one non-weight-bearing leg, making it the most appropriate choice in this scenario.
Choice D Reason:
The swing-through gait is used by clients who have good upper body strength and can bear weight on both legs, even if one leg is weaker. This gait involves moving both crutches forward together and then swinging both legs through to the crutches. It is not suitable for a client who can only bear weight on one leg, as it requires some degree of weight-bearing on both legs.
A nurse on a surgical unit is caring for a client who is scheduled for surgery. The client states, “I cannot do this. I do not want this surgery.” Which of the following actions should the nurse take?
Explanation
Choice A Reason:
Telling the client about the benefits of the surgery might seem helpful, but it does not address the client’s immediate concern. The client has expressed a clear decision to refuse the surgery, and the nurse must respect this decision by informing the surgeon. This approach aligns with the ethical principle of respecting patient autonomy.
Choice B Reason:
Letting the client know that their surgeon will be notified of their decision is the correct action. This respects the client’s autonomy and ensures that the surgeon is aware of the client’s wishes. It also allows for further discussion between the client and the surgeon, where the client can receive more detailed information and support.
Choice C Reason:
Reassuring the client that it is expected to be nervous before surgery is supportive but does not address the client’s refusal. While it is important to acknowledge the client’s feelings, the nurse must also take appropriate steps to respect the client’s decision and inform the surgeon.
Choice D Reason:
Informing the client that it is too late to stop the surgery is incorrect and unethical. Patients have the right to refuse treatment at any time, and it is the nurse’s duty to respect and facilitate this decision.
A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?
Explanation
Choice A Reason
Documenting the indications for using wrist restraints is an important step in the process, but it is not the first action the nurse should take. Documentation ensures that there is a clear rationale for the use of restraints and helps in maintaining legal and ethical standards1. However, before documenting, the nurse must explore and attempt less restrictive alternatives to ensure that restraints are truly necessary.
Choice B Reason
Obtaining a prescription for restraints from the provider is a crucial step, as restraints should only be used with a valid order from a healthcare provider. This ensures that the use of restraints is medically justified and that the provider is aware of the client’s condition. However, before seeking a prescription, the nurse must first attempt less restrictive alternatives to manage the client’s behavior.
Choice C Reason
Explaining the procedure to the client and their family is essential for informed consent and to ensure that they understand the reasons for using restraints. This step helps in maintaining transparency and trust. However, it should be done after the nurse has determined that less restrictive alternatives are not effective and that restraints are necessary.
Choice D Reason
Attempting less restrictive alternatives is the first action the nurse must take. This approach aligns with ethical and legal guidelines that emphasize the use of the least restrictive measures to ensure the client’s safety. Alternatives may include verbal de-escalation, environmental modifications, or the use of less restrictive devices. Only if these measures fail should the nurse consider using restraints.
A nurse is administering multiple types of ophthalmic drops to a client. Which of the following actions should the nurse take?
Explanation
Choice A Reason
Waiting 5 minutes between the administration of each medication is the most appropriate action. This allows each medication to be absorbed properly without being washed away by the subsequent drops. Adequate absorption ensures that each medication can exert its therapeutic effect effectively.
Choice B Reason
Asking the client to close their eyes tightly after instilling each medication is not recommended. This action can force the medication out of the eye, reducing its effectiveness. Instead, clients should be advised to close their eyes gently to allow the medication to spread evenly across the eye surface.
Choice C Reason
Holding the dropper 3 cm (1.2 in) away from the client’s eye is too far. The recommended distance is about 1 to 2 cm (0.4 to 0.8 in) to ensure that the drops are accurately placed in the conjunctival sac without touching the eye or eyelashes, which could cause contamination.
Choice D Reason
Massaging the client’s eyelids for 20 seconds after instillation is not a standard practice for administering ophthalmic drops. This action could potentially irritate the eye or cause discomfort. Instead, gentle pressure can be applied to the inner corner of the eye (nasolacrimal duct) for a few seconds to prevent the medication from draining into the tear duct.
A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?
Explanation
Choice A Reason
Using sterile gloves to obtain the sputum specimen is important for maintaining sterility and preventing contamination. However, it is not the first priority action. The timing of the collection is more critical to ensure the accuracy and quality of the specimen.
Choice B Reason
Obtaining the sputum specimen after the client uses mouthwash is incorrect. Mouthwash can kill or alter the microorganisms present in the sputum, leading to inaccurate test results. The client should rinse their mouth with water instead to reduce contamination from oral secretions.
Choice C Reason
Collecting the sputum specimen in the morning is the most appropriate action. Sputum accumulates overnight, making it easier to collect a sufficient sample in the morning. This timing also ensures that the specimen is more concentrated and representative of the lower respiratory tract.
Choice D Reason
Placing the sputum specimen in a clean container is necessary, but it is not the first action to take. The container should be sterile to prevent contamination and ensure the accuracy of the test results. However, the timing of the collection is more critical to obtaining a quality specimen.
A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include?
Explanation
Choice A Reason:
Changing the dressing four times per day is excessive and not typically recommended. Most guidelines suggest changing the dressing once a day or as needed if it becomes soiled or wet. Over-frequent dressing changes can disrupt the healing process and increase the risk of infection.
Choice B Reason:
Applying tincture of benzoin prior to removing the dressing is not a standard practice for wound care. Tincture of benzoin is usually used to increase the adhesion of bandages or tapes, not for removing dressings. Using it inappropriately could cause skin irritation or damage.
Choice C Reason:
Cleaning from the incision to the surrounding skin is the correct method. This technique helps prevent the spread of bacteria from the surrounding skin into the incision site, reducing the risk of infection. Always use a sterile solution and clean gauze for this process.
Choice D Reason:
Using sterile gloves when removing the old dressing is important to maintain a sterile environment and prevent infection. However, this is a general practice and not specific to the wound care instructions provided in the question.
Sign Up or Login to view all the 58 Questions on this Exam
Join over 100,000+ nursing students using Nursingprepexams’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.
Sign Up Now
