Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?
A. Evaluate the need for the client to remain in mitten restraints.
B. Assist the client with range-of-motion exercises of the hands.
Range-of-motion exercises can be safely performed by assistive personnel under the supervision and direction of the nurse. It helps to maintain the mobility and function of the client's hands while in restraints.
C. Instruct the client's family about the purpose of mitten restraints.
D. Determine the circulation status of the affected extremities every 2 hr
This question is an excerpt from Nurse Dive's nursing test bank - PN Comprehensive Predictor PN 2020 Proctored Exam. Take the full exam now
Full Explanation
Range-of-motion exercises can be safely performed by assistive personnel under the supervision and direction of the nurse. It helps to maintain the mobility and function of the client's hands while in restraints.
Similar Questions
A nurse is caring for a client who has major depressive disorder and is taking an antidepressant. The nurse should identify which of the following findings as the priority to report to the provider?
A. The client has a sudden increase in energy.
The nurse should identify the sudden increase in energy as the priority finding to report to the provider. This could be a sign of an emerging manic episode, especially if the client is taking an antidepressant alone without a mood stabilizer. It may indicate a switch to a manic state or the development of bipolar disorder. The provider needs to be informed promptly so that appropriate assessment and interventions can be implemented to ensure the client's safety and well-being.
B. The client is withdrawn and uncommunicative.
C. The client neglects personal hygiene.
D. The client reports a change in sleeping patterns.
Full Explanation
The nurse should identify the sudden increase in energy as the priority finding to report to the provider. This could be a sign of an emerging manic episode, especially if the client is taking an antidepressant alone without a mood stabilizer.
It may indicate a switch to a manic state or the development of bipolar disorder. The provider needs to be informed promptly so that appropriate assessment and interventions can be implemented to ensure the client's safety and well-being.
A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider?
A. Weight loss of 1 kg (2.2 lb) in the past 24 hr
B. Pale, clammy skin
C. Fatigue when ambulating 152 m (500 ft)
D. Productive cough with pink, frothy sputum
A productive cough with pink, frothy sputum is indicative of pulmonary edema, which is a serious manifestation of left-sided heart failure. It suggests fluid accumulation in the lungs, impairing gas exchange and oxygenation. Prompt notification of the provider is crucial for appropriate intervention and management of the client's condition.
Full Explanation
A productive cough with pink, frothy sputum is indicative of pulmonary edema, which is a serious manifestation of left-sided heart failure.
It suggests fluid accumulation in the lungs, impairing gas exchange and oxygenation.
Prompt notification of the provider is crucial for appropriate intervention and management of the client's condition.
A nurse on a mental health unit observes a client yelling at another client. Which of the following actions should the nurse take first?
A. State expectations for the client's behavior.
By stating expectations for the client's behavior, the nurse is addressing the immediate situation and setting clear boundaries. This intervention allows the nurse to assertively communicate with the client, reminding them of appropriate behavior and potentially diffusing the situation. It also helps maintain a therapeutic and safe environment for all clients on the unit.
B. Request security personnel restrain the client.
Requesting security personnel to restrain the client should be a last resort, used only when the client poses a significant risk to themselves or others and all other de-escalation techniques have failed. Restraint can be traumatic and has potential physical and psychological risks.
C. Place the client in seclusion.
Placing the client in seclusion is another measure that should be used sparingly and only when necessary for the safety of the client or others. It’s important to try less restrictive measures first, such as verbal de-escalation techniques or offering a quiet, private space where the client can regain control.
D. Debrief staff members about the conflict.
Debriefing staff members about the conflict is an important step, but it should not be the first action. The immediate priority is to ensure the safety of all clients and to de-escalate the situation.
Full Explanation
The correct answer is Choice A.
Choice A rationale: By stating expectations for the client’s behavior, the nurse is addressing the immediate situation and setting clear boundaries. This intervention allows the nurse to assertively communicate with the client, reminding them of appropriate behavior and potentially diffusing the situation1.
Choice B rationale: Requesting security personnel to restrain the client should be a last resort, used only when the client poses a significant risk to themselves or others and all other de-escalation techniques have failed. Restraint can be traumatic and has potential physical and psychological risks.
Choice C rationale: Placing the client in seclusion is another measure that should be used sparingly and only when necessary for the safety of the client or others. It’s important to try less restrictive measures first, such as verbal de-escalation techniques or offering a quiet, private space where the client can regain control.
Choice D rationale: Debriefing staff members about the conflict is an important step, but it should not be the first action. The immediate priority is to ensure the safety of all clients and to de-escalate the situation.