While performing hygiene care for a client, a nurse notices a frayed electrical cord on the client’s electronic blood pressure monitor.
Which of the following actions should the nurse take first?
Remove the device from the room.
Access the facility’s maintenance protocol.
Report defective equipment.
Request a replacement device.
The Correct Answer is A
This is because a frayed electrical cord can pose a serious risk of electric shock or fire to the client and the nurse.
The nurse should act quickly to eliminate the hazard and ensure the safety of the client and others.
Choice B is wrong because accessing the facility’s maintenance protocol is not the first action the nurse should take.
The nurse should prioritize removing the device from the room before following any protocol.
Choice C is wrong because reporting defective equipment is not the first action the nurse should take.
The nurse should prioritize removing the device from the room before reporting it to the appropriate authority.
Choice D is wrong because requesting a replacement device is not the first action the nurse should take.
The nurse should prioritize removing the device from the room before requesting a new one.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. The client who says “I need to learn how to perform a dressing change on my leg” is indicating an acceptance of the limb loss and a readiness to learn self-care skills.
This is a positive sign of coping and adaptation after an amputation surgery.
Choice A is wrong because the client who says “I am going to have to find someone who can take care of my leg at home” is expressing dependency and denial of the limb loss.
The client needs to be encouraged to participate in self-care activities and rehabilitation.
Choice B is wrong because the client who says “I stay awake at night because I keep thinking about my leg” is experiencing phantom limb sensation, which is a common phenomenon after amputation.
The client may benefit from pain management, distraction techniques, and counseling.
Choice D is wrong because the client who says “I know my family means well, but I don’t want visitors seeing my leg right now” is showing signs of social isolation and low self-esteem.
The client needs emotional support and reassurance from the nurse and family members.
Normal ranges for vital signs after amputation are blood pressure 120/80 mm Hg, pulse 60-100 beats/min, respiratory rate 12-20 breaths/min, and temperature 36.5-37.5°C.
Correct Answer is D
Explanation
It can also increase the risk of denture stomatitis and pneumonia.
Dentures should be removed overnight and soaked in a denture-cleansing solution.
Choice A is wrong because rinsing dentures after meals can help remove food debris and prevent plaque buildup.
Choice B is wrong because soaking dentures in water after removal can prevent them from drying out and losing their shape.
However, water alone is not enough to disinfect dentures, so a denturecleansing solution should also be used.
Choice C is wrong because applying an adhesive to seal dentures in place can improve the fit and comfort of dentures.
However, adhesive should not be used as a substitute for poorly fitting dentures, and any excess adhesive should be removed by brushing.
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