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1. A nurse is providing care for a client with dementia who frequently wanders. What is the best strategy to ensure their safety?
- A. Use restraints to prevent wandering
- B. Encourage the client to walk in a monitored area
- C. Place a bed exit alarm system
- D. Ask family members to stay with the client at all times
Correct answer: C
Rationale: The best strategy to ensure the safety of a client with dementia who frequently wanders is to place a bed exit alarm system. This system alerts staff when the client attempts to leave the bed, reducing the risk of falls. Choice A, using restraints, is not the best approach as it can lead to complications and is not recommended unless absolutely necessary. Choice B, encouraging the client to walk in a monitored area, may not be effective in preventing wandering as the client may still wander away. Choice D, asking family members to stay with the client at all times, may not be feasible or practical, especially for round-the-clock supervision.
2. A nurse is delegating the collection of a sputum specimen to an assistive personnel (AP). At which of the following times should the nurse instruct the AP to collect the specimen?
- A. In the afternoon
- B. As soon as the client awakens in the morning
- C. Before bedtime
- D. Immediately after lunch
Correct answer: B
Rationale: The correct answer is B: 'As soon as the client awakens in the morning.' Sputum specimens should be collected early in the morning to obtain a concentrated sample. This timing ensures that the specimen is less diluted, providing a more accurate analysis. Choices A, C, and D are incorrect as they do not align with the optimal timing for collecting a sputum specimen, which is in the morning.
3. Which instruction is crucial for a client with diabetes being discharged?
- A. Take insulin only when feeling unwell
- B. Administer insulin before meals as prescribed
- C. Monitor blood sugar levels weekly
- D. Check blood sugar once in the morning
Correct answer: B
Rationale: Administering insulin before meals as prescribed is crucial for a client with diabetes being discharged because it ensures proper blood sugar control. Choice A is incorrect because insulin should not be taken only when feeling unwell; it should be taken as prescribed. Choice C is incorrect as monitoring blood sugar levels weekly may not provide timely adjustments to insulin doses. Choice D is incorrect as checking blood sugar only once in the morning is not sufficient for proper diabetes management.
4. A healthcare professional is reviewing the laboratory report of a client who is receiving filgrastim. Which of the following laboratory values should the healthcare professional monitor to determine the effectiveness of the treatment?
- A. WBC count.
- B. Serum potassium.
- C. Hemoglobin level.
- D. Serum creatinine.
Correct answer: A
Rationale: Filgrastim works by stimulating the production of white blood cells. Therefore, monitoring the white blood cell (WBC) count is essential to assess the effectiveness of the treatment. Choice B, serum potassium, is not directly affected by filgrastim therapy. Choice C, hemoglobin level, is important but not the primary indicator of filgrastim's effectiveness. Choice D, serum creatinine, is unrelated to the action of filgrastim and would not reflect its effectiveness.
5. A client with COPD is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?
- A. Administer oxygen at 2 L/min via nasal cannula
- B. Encourage pursed-lip breathing
- C. Position the client in high Fowler's position
- D. Encourage deep breathing and coughing
Correct answer: B
Rationale: The correct intervention for a client with COPD is to encourage pursed-lip breathing. Pursed-lip breathing helps maintain airway patency by preventing the collapse of small airways during exhalation, improving breathing efficiency. Administering oxygen at 2 L/min via nasal cannula may be appropriate for some COPD patients but is not the priority intervention. Positioning the client in high Fowler's position may help improve breathing but is not as specific as pursed-lip breathing for COPD. Encouraging deep breathing and coughing may be beneficial in other respiratory conditions, but it is not the most effective intervention for COPD.
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