A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?

Ensure that prescribed medications are kept in a safe place in the room.

Remove soft drink cans from the nurse's desk and patient lounge.

Replace paper trash bags with plastic biohazard bags.

Take the client's cellular telephone and provide a telephone in the room.

Answer and Explanation

The Correct Answer is B

Rationale

A. This action is important to prevent unauthorized access to medications by the client or other patients. However, this is not the priority

B. Soft drink cans can potentially be used to harm oneself or others (e.g., by smashing or as a cutting tool). Removing these items helps to reduce the risk of self-injury or harm to others.

C. This action is typically done to safely dispose of any items that may be considered biohazardous, such as used tissues, bandages, or any items contaminated with bodily fluids. It helps to maintain infection control and prevent exposure to potentially infectious materials.

D. In some mental health units, clients may not be allowed to have personal electronic devices due to concerns about confidentiality, safety, or potential disruption. Providing a unit-controlled telephone allows staff to monitor communication and ensure it is appropriate and supportive

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Correct Answer is C

Explanation

Rationale

A. This comment suggests that the client is aware of the correct technique (inhaling and holding breath) but finds it difficult to execute properly. It indicates a partial understanding of the inhaler technique but potential difficulty in coordination.

B. This comment indicates a misunderstanding of the purpose of a rescue inhaler. Rescue inhalers are intended to be used promptly at the onset of symptoms to relieve acute shortness of breath. Delaying use until symptoms are severe may result in inadequate relief and worsening of respiratory distress.

C. This comment suggests that the client may be swallowing the medication instead of inhaling it into the lungs. Inhalers are meant to deliver medication directly into the lungs through inhalation, not swallowing. Swallowing the medication can lead to gastrointestinal side effects like nausea.

D. Shaking the inhaler before use is a correct step to ensure proper dispersion of the medication. This comment indicates the client understands and follows this part of the inhaler technique correctly.

A. Neurology unit supervisor. B. Nurse case manager. C. Adult nurse practitioner. D. Risk management nurse.

Correct Answer is B

Explanation

Rationale

A. This role oversees the neurology unit but may not be directly involved in ICU care coordination, which requires a focus on acute management and transition to rehabilitation.

B. Nurse case managers are skilled in coordinating care for patients with complex conditions, ensuring continuity of care, and facilitating communication among healthcare providers and the client's family.

C. While an NP may be involved in direct patient care, their role is more focused on clinical management rather than comprehensive care coordination across different disciplines.

D. This role deals with patient safety and risk reduction but is not primarily responsible for coordinating care for a specific patient's acute medical needs and rehabilitation planning.

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A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

Correct Answer is B

Explanation

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which intervention(s) should the nurse take to prepare the body before the family enters the room? Select all that apply.

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

Exhibits The nurse is reviewing the client's chart. For each finding, click to indicate whether findings suggest that the client's condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

The nurse is teaching dietary modifications to a client with hypertension. Which product is the best selection to include as part of the client's lunch?