A nurse assesses a patient with restraints. The nurse should:

Loosen the restraints and assess the patient’s skin.

Document the findings in the patient’s chart.

Continue to monitor the patient without making any changes.

Apply ice packs to reduce swelling.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Loosening the restraints and assessing the patient’s skin is important, but it should be done as part of a regular assessment and not as the first action. The nurse should first document the findings to ensure accurate and timely communication of the patient’s condition.
Choice B rationale
Documenting the findings in the patient’s chart is the correct action. Accurate documentation is essential for communicating the patient’s condition and any interventions performed. It ensures continuity of care and provides a legal record of the patient’s status and the care provided.
Choice C rationale
Continuing to monitor the patient without making any changes is not appropriate. The nurse should assess the patient’s condition and document the findings to ensure that any necessary interventions are performed promptly.
Choice D rationale
Applying ice packs to reduce swelling is not appropriate in this context. The nurse should first document the findings and then assess the need for any interventions based on the patient’s condition.

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Correct Answer is D

Explanation

Choice A rationale
Ignoring the comment and documenting “No Known Allergies” (NKA) is incorrect because it disregards the client’s report of an allergy. This action could lead to potential harm if the client is indeed allergic to codeine.
Choice B rationale
Asking the client why they think it is an allergy is not the best response. It may come across as dismissive and does not provide the nurse with specific information about the client’s allergic reaction.
Choice C rationale
Telling the client not to worry and that they will be okay if they take codeine with food is incorrect. This response is dismissive of the client’s concern and does not address the potential for an allergic reaction.
Choice D rationale
Asking the client what symptoms they experience with codeine is the best response. It allows the nurse to gather specific information about the client’s allergic reaction, which is crucial for safe medication administration.

A. Affective. B. Cognitive. C. Psychomotor. D. Behavioral.

Correct Answer is B

Explanation

Choice A rationale
The affective domain involves emotions and attitudes, which is not the primary focus when teaching a newly diagnosed diabetic patient about their condition.
Choice B rationale
The cognitive domain involves knowledge and understanding. Teaching a newly diagnosed diabetic patient involves providing information about the disease, its management, and self- care practices, which falls under the cognitive domain.
Choice C rationale
The psychomotor domain involves physical skills, which is not the primary focus in this context.
Choice D rationale
The behavioral domain is not a recognized learning domain in this context. The correct domain for teaching a newly diagnosed diabetic patient is cognitive.

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A nurse assesses a patient with restraints. The nurse should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client states they have an allergy to codeine. Which is the best response by the nurse?

Correct Answer is D

Explanation

A nurse is providing teaching to a newly diagnosed diabetic patient. The nurse recognizes this as which learning domain?

Correct Answer is B

Explanation

A nurse administers the wrong medication to a patient, resulting in harm. This situation primarily involves which legal concept?

During a health assessment, a client complains of palpitations. Which of the following is subjective data?

A nurse is caring for a client with diabetes who needs dietary or nutrition education.

A client diagnosed with terminal cancer says, “I’m going to die, and I wish my family would stop hoping for a cure. I get so angry when they carry on like this. After all, I’m the one who’s dying.”. Which response by the nurse is therapeutic?

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Which patient below is best assigned to the LPN?

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