Extract:

Question 1 of 5

A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (Select all that apply.)

A. Obtain the provider's prescription renewal every 72 hr.B. Document restraint checks and client status every 2 hr.C. Implement passive range-of-motion exercises.D. Educate the client's family about restraint use.E. Release the restraint and reposition the client every 4 hr.

Correct Answer: A,B,C,D

Rationale: Obtain the provider's prescription renewal every 72 hr.: This is an essential intervention. Document restraint checks and client status every 2 hr.: Regular documentation is vital. Implement passive range-of-motion exercises: Important for preventing joint stiffness. Educate the client's family about restraint use: Provides transparency and support.

Question 2 of 5

A nurse in reviewing the laboratory data on a client who has a new prescription for heparin for treatment of a pulmonary embolism. Which of the following data should the nurse report to the provider?

A. Partial thromboplastin time (PTT) 65 secondsB. Hematocrit 45%C. White blood cell count 8.000/mm3D. Platelets

Correct Answer: A

Rationale: Partial thromboplastin time (PTT) 65 seconds: The normal PTT range is typically between 25 to 35 seconds for patients not on anticoagulants. For a patient receiving heparin therapy, the therapeutic PTT range is usually 1.5 to 2.5 times the normal value, which translates to approximately 60 to 100 seconds. A PTT of 65 seconds is at the lower end of the therapeutic range and may require adjustment in dosage or closer monitoring, especially if there are concerns about achieving adequate anticoagulation for the treatment of a pulmonary embolism. It is important to report this value to the provider.

Question 3 of 5

Clients with special needs require specific communication techniques. Which specific communication techniques should a nurse utilize when caring for a client who is cognitively impaired?

A. Keep communication simple and concreteB. Focus on the clients familyC. Use open-ended questionsD. Demonstrate or pantomime ideas

Correct Answer: A

Rationale: Keep communication simple and concrete: Using simple, straightforward language helps clients who are cognitively impaired to better understand the information being conveyed. Concrete language minimizes confusion and makes it easier for the client to process and respond to what is being said, promoting effective communication.

Question 4 of 5

The nurse assesses patients to determine their risk for healthcare acquired infections. Which hospitalized patient would the nurse consider most at risk for developing this type of infection?

A. A 60 year old patient who is on a mechanical ventilatorB. A 65 year old patient who is vegetarian and obeseC. A 45 year old patient who smokes a pack of cigarettes a dayD. A 70 year old patient who has a normal WBC count

Correct Answer: A

Rationale: A 60 year old patient who is on a mechanical ventilator: This patient is at the highest risk for healthcare-acquired infections (HAIs) due to the use of mechanical ventilation.

Question 5 of 5

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

A. I will keep my walker at the end of my bed.B. I will place an area rug at the entry of my bathroom.C. I will keep the fluorescent ceiling light in my room at night.D. I will place a bath seat in my shower to use when I bathe.

Correct Answer: D

Rationale: I will place a bath seat in my shower to use when I bathe: This statement indicates an understanding of safety measures to prevent falls while bathing. Using a bath seat can provide stability and allow the client to bathe safely while reducing the risk of slipping or losing balance in the shower.