A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement.
The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

Tell the client that the surgeon will prescribe restraints if they try to leave.

Explain to the client that they cannot leave until the surgeon discharges them.

Have the client sign an against medical advice form.

Administer a sedative medication to the client.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: Explain to the client that they cannot leave until the surgeon discharges them.

Choice B rationale: The nurse should explain the importance of following the surgeon's orders and the potential consequences of leaving before being officially discharged. This approach provides patient education and promotes collaboration between the client and the health care team. It also ensures the client understands that leaving without proper discharge could lead to complications or inadequate recovery.

Choice A rationale: Threatening the client with restraints is not an appropriate action, as it may cause undue stress and escalate the situation. Restraints should only be used as a last resort in cases where the client poses an immediate risk of harm to themselves or others.

Choice C rationale: While having the client sign an against medical advice (AMA) form might be appropriate if the client insists on leaving, the nurse should first attempt to educate the client on the importance of following the surgeon's orders and collaborate with the client to resolve any concerns or issues leading to their desire to leave.

Choice D rationale: Administering a sedative medication is not an appropriate action in this situation. Sedation should only be used when medically necessary and not as a means to control a client's behavior or decisions.

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Correct Answer is C

Explanation

The correct answer is choice C. Use a filter needle to aspirate the medication.

This is because a filter needle can prevent glass particles from being drawn into the syringe when aspirating medication from an ampule.

Glass particles can cause harm to the patient if injected.

Choice A is wrong because cleansing the tip of the ampule with an alcohol swab after opening is not necessary and may contaminate the medication.

Choice B is wrong because adding 0.5 mL of diluent to the medication may alter the concentration and dosage of the medication.

Choice D is wrong because injecting air into the ampule prior to drawing the medication into a syringe is not required and may create pressure that can cause the ampule to break.

A. Lowering the side rail on the side of the bed where they will stand to perform mouth care. B. Using an oral care sponge swab moistened with cool water to clean the client’s mouth. C. Wearing clean gloves to perform mouth care for the client. D. Using two gloved fingers to open the client’s mouth for cleaning.

Correct Answer is D

Explanation

The correct answer is D. Using two gloved fingers to open the client’s mouth for cleaning.

Choice A rationale:

Lowering the side rail on the side of the bed where the AP will stand is necessary for safe access to the client. However, the AP should ensure the opposite side rail is up to prevent the client from falling.

Choice B rationale:

Using an oral care sponge swab moistened with cool water is an appropriate method for cleaning the mouth of an unconscious client. It helps maintain oral hygiene and comfort.

Choice C rationale:

Wearing clean gloves is essential for infection control and is a standard practice when performing mouth care to protect both the client and the caregiver.

Choice D rationale:

Using two gloved fingers to open the client’s mouth is not recommended as it can cause injury to the caregiver if the client bites down reflexively. Instead, a padded tongue blade should be used to gently open the mouth.

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A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

Correct Answer is C

Explanation

A nurse observes assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is D

Explanation

A nurse is caring for a client who has a hip fracture and plans to administer pain medication prior to turning the client. Which of the following ethical principles is the nurse implementing?

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A nurse is caring for a client who has experienced a cerebrovascular accident with resulting dysphagia. Which of the following therapists assists clients to learn to eat with less risk of aspiration?

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A nurse is planning to place a client into the Sims’ position. Which of the following actions should the nurse plan to take?

A nurse is collecting data about a client’s oral care. The client wears dentures and reports having mouth sores. The nurse should identify which of the following oral care practices by the client as a possible cause of the mouth sores?

A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement.
The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?