A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?

"I will gently restrain him during seizures."

"I will loosen his clothing during seizures."

"I will insert a washcloth in his mouth during seizures."

"I will turn him on his back during seizures."

Answer and Explanation

The Correct Answer is B

A.   "I will gently restrain him during seizures."- Restraint during seizures can cause injury and is not recommended.
B.   "I will loosen his clothing during seizures."- Loosening tight clothing helps prevent injury and ensures adequate ventilation during a seizure.
C.   "I will insert a washcloth in his mouth during seizures."- Inserting objects into the mouth during a seizure can cause injury or obstruct the airway.

D.   "I will turn him on his back during seizures."- Placing the client on their back during a seizure can increase the risk of aspiration. The recovery position is preferred

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Correct Answer is C

Explanation

A. Verifying the bilirubin level of the tube contents is not a reliable method for confirming tube placement and may not provide accurate information.
B. Auscultating for air insufflation can help detect tube placement in the respiratory tract but may not reliably confirm placement in the gastrointestinal tract.
C. Requesting a chest x-ray is the most reliable method for confirming the placement of a feeding tube, as it allows visualization of the tube's position relative to anatomical landmarks.
D. Checking the pH level of gastric contents can help differentiate between gastric and respiratory placement but may not provide definitive confirmation of tube placement.

A. Return the medication to the medication cabinet. B. Notify the provider of the client's refusal. C. Document the refusal in the client's medical record. D. Inform the client of the potential consequences of their refusal

Correct Answer is D

Explanation

A. Return the medication to the medication cabinet- Returning the medication without addressing the client's concerns does not promote understanding or collaboration.
B. Notify the provider of the client's refusal- Notifying the provider is important but should come after attempting to address the client's concerns.
C. Document the refusal in the client's medical record- Documentation is necessary but should follow a discussion with the client.
D. Inform the client of the potential consequences of their refusal- The nurse should first educate the client about the risks associated with not taking their antihypertensive medication to ensure they are making an informed decision.

View Question and Answer

Body System	Findings
Neurological	Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal	Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory	: Lungs clear
Cardiovascular	: Heart rate irregular, Heart rate 95/min
Gastrointestinal	Bowel sounds hyperactive x 4 quadrants

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A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking for proper placement of a feeding tube. Which of the following methods is the most reliable for verification of tube placement?

Correct Answer is C

Explanation

A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy." Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which of the following volumes should the nurse record on the I&O?

A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?

A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification and. Which of the following actions should the nurse take to verify the client's identity?

A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?

A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?