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1. A nurse is providing care for a client with dementia who frequently wanders. What is the best strategy to ensure their safety?
- A. Use restraints to prevent wandering
- B. Encourage the client to walk in a monitored area
- C. Place a bed exit alarm system
- D. Ask family members to stay with the client at all times
Correct answer: C
Rationale: The best strategy to ensure the safety of a client with dementia who frequently wanders is to place a bed exit alarm system. This system alerts staff when the client attempts to leave the bed, reducing the risk of falls. Choice A, using restraints, is not the best approach as it can lead to complications and is not recommended unless absolutely necessary. Choice B, encouraging the client to walk in a monitored area, may not be effective in preventing wandering as the client may still wander away. Choice D, asking family members to stay with the client at all times, may not be feasible or practical, especially for round-the-clock supervision.
2. How should a healthcare provider assess and manage a patient with anemia?
- A. Monitor hemoglobin levels and provide iron supplements
- B. Administer B12 injections
- C. Monitor for signs of infection and administer folic acid
- D. Administer oxygen therapy
Correct answer: A
Rationale: Corrected Question: To assess and manage a patient with anemia, monitoring hemoglobin levels and providing iron supplements are crucial. Anemia is commonly caused by iron deficiency, making iron supplementation a cornerstone of treatment. B12 injections (Choice B) are more relevant for treating megaloblastic anemia, not the typical iron-deficiency anemia. Monitoring for signs of infection and administering folic acid (Choice C) are important in specific types of anemia like megaloblastic anemia, but not the first-line approach for anemia management. Administering oxygen therapy (Choice D) is not the primary intervention for anemia unless severe hypoxemia is present, which is not typically seen in anemia.
3. What is the primary intervention for sepsis?
- A. Administer IV antibiotics
- B. Monitor blood pressure
- C. Administer fluids
- D. All of the above
Correct answer: D
Rationale: The primary intervention for sepsis involves a multifaceted approach, including administering IV antibiotics to address the underlying infection and administering fluids to stabilize the patient's hemodynamic status. Monitoring blood pressure is important in the management of sepsis, but it is not the sole primary intervention. Therefore, the correct answer is 'All of the above' as it encompasses the comprehensive approach required for effective sepsis management.
4. A client is constipated and asks the nurse for advice. What should the nurse recommend?
- A. Administer a laxative to relieve discomfort
- B. Increase dietary fiber to promote bowel movements
- C. Advise the client to rest until symptoms resolve
- D. Encourage bed rest to allow bowel function to return
Correct answer: B
Rationale: The correct recommendation for constipation is to increase dietary fiber to promote bowel movements. Dietary fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Administering a laxative (Choice A) is not the first-line recommendation and should be used cautiously due to potential side effects. Resting until symptoms resolve (Choice C) and encouraging bed rest (Choice D) are not effective interventions for relieving constipation.
5. When providing discharge instructions for a client with home oxygen, what safety measure should the nurse emphasize?
- A. Prohibit smoking near oxygen equipment
- B. Ensure the client uses non-flammable bedding
- C. Ensure oxygen tanks are stored upright
- D. Keep the oxygen equipment at least 6 feet away from heat sources
Correct answer: D
Rationale: The correct answer is to keep the oxygen equipment at least 6 feet away from heat sources. Placing oxygen equipment near heat sources can lead to fire hazards due to the oxygen's combustible nature. Option A is the correct safety measure as smoking near oxygen equipment can cause fires due to oxygen's flammable properties. Option B regarding the use of non-flammable bedding is not directly related to oxygen safety. Option C is important for proper oxygen tank functioning but is not as critical as keeping the equipment away from heat sources to prevent fires.
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