Correct Answer: B

Rationale: 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. '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. '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. '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.

Correct Answer: C

Rationale: 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. 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. 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. 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.

Correct Answer: C

Rationale: 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. 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. 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. 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.

Correct Answer: D

Rationale: 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 standards. However, before documenting, the nurse must explore and attempt less restrictive alternatives to ensure that restraints are truly necessary. 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. Explaining the procedure to the client and their family is an important step in obtaining informed consent and maintaining transparency. However, it should be done after the nurse has determined that less restrictive alternatives are not effective and that restraints are necessary. 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.

Correct Answer: D

Rationale: The thumb and toe pads are thicker and more painful; the ear isn’t standard. The side of the ring finger is ideal due to its capillary supply and lower sensitivity.