Solutions
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 Answers 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 Answers 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 Answers 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 Answers 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?
Don't worry. Your healthcare provider knows what's best for
you Correct Answers C.