The nurse receives a report at the beginning of the shift and learns that the client scores 7 on the Glasgow Coma Scale. The nurse realizes that this client is at which of the following levels of consciousness?

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Question 1 of 5

The nurse receives a report at the beginning of the shift and learns that the client scores 7 on the Glasgow Coma Scale. The nurse realizes that this client is at which of the following levels of consciousness?

Correct Answer: A

Rationale: A Glasgow Coma Scale score of 7 indicates coma minimal responsiveness below 8. Higher scores denote disability or alertness. Nurses assess this for neurological status.

Question 2 of 5

Which intervention is important for maintaining the safety of an immobile patient?

Correct Answer: D

Rationale: Implementing fall prevention measures is critical for an immobile patient's safety, involving tools like bed alarms, low beds, or assistance during transfers to mitigate risks in a controlled environment. Immobile patients can't walk independently, so promoting frequent movement isn't feasible and could increase danger. Physical or soft restraints, while sometimes considered, are last-resort options due to ethical and safety concerns, not primary safety strategies. Fall prevention directly addresses the vulnerability of those unable to reposition themselves, reducing injury risk a key nursing responsibility. This approach ensures a safe setting, balancing protection with patient dignity, and aligns with evidence-based practice to minimize harm in immobile populations.

Question 3 of 5

Which nursing intervention is essential to prevent pressure ulcers in a patient with limited mobility?

Correct Answer: A

Rationale: Frequent, thorough skin assessments are essential to prevent pressure ulcers in limited-mobility patients, catching early redness or breakdown for timely intervention. Petroleum jelly doesn't relieve pressure, air mattresses aid but aren't enough alone, and prolonged sitting increases risk. Nurses rely on this to monitor skin health, enabling prompt action like repositioning, crucial for preventing progression to ulcers in at-risk areas.

Question 4 of 5

A nurse is caring for a client receiving oxygen therapy via a nasal cannula. What is an important complication associated with prolonged use of a nasal cannula?

Correct Answer: A

Rationale: Dry nasal passages (A) are a common complication of prolonged nasal cannula use, as unhumidified oxygen dries mucosa, causing discomfort or bleeding. Hypoventilation (B) isn't typical with low-flow devices. Hyperoxygenation (C) requires higher flows. Infection risk (D) isn't direct. Humidification prevents this, per nursing care, ensuring patient tolerance.

Question 5 of 5

A mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse's explanation is based on the knowledge that lead poisoning is treated with:

Correct Answer: B

Rationale: Lead poisoning is treated with chelating agents like succimer or EDTA, which bind lead in the bloodstream, facilitating its excretion and reducing toxicity a standard protocol for elevated blood levels. Gastric lavage or charcoal addresses acute ingestion, not chronic exposure common in children, while antiemetics manage symptoms, not the cause. Nurses explain this to parents, emphasizing chelation's role in reversing neurological and systemic damage, ensuring understanding of the treatment's purpose and process.

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