The client complaints of frequent nocturia. High-frequency hearing tones are perceptible. Voluntary and autonomic reflexes are slowed. 90. The nurse plans to wear this protective mask (see figure) when caring for clients with certain disorders. What are these disorders? Select all that apply. Scabies Hepatitis A Tuberculosis Pharyngeal diphtheria Streptococcal pharyngitis Meningococcal pneumonia 91. Wrist restraints have been prescribed for a client who is constantly pulling at his gastrostomy tube. Which findings does the nurse, developing a care plan, recognize as unexpected outcomes related to the use of restraints? Select all that apply. The client becomes agitated. The skin under the restraint is red. The client’s left hand is pale and cold. The client verbalizes the reason for the restraints. The client is unable to reach the gastrostomy tube with his hands. The client slips his hand from its restraint and pulls at his gastrostomy tube. 92. A nurse is discussing accident prevention with the family of an older client who is being discharged from the hospital after hip surgery. This client has a tendency to be forgetful. Which items in the home increase the client’s risk for injury? Select all that apply. A nightlight in the bathroom Elevated toilet seat with armrests Cooking equipment such as a stove Smoke and carbon monoxide detectors Common household objects such as doormats A water heater thermostat adjusted to a low setting 93. In which of the following situations would the nurse use this type of restraint (see figure)? Select all that apply. To secure the shoulders and the waist To immobilize a client’s arm and shoulders To prevent the client from getting out of bed To prevent dislodgment of an intravenous line To prevent the client from turning from side to side To prevent the use of the hands while allowing free arm movement 94. A home care nurse is visiting an older client who has been recovering from a mild brain attack (stroke) afecting her left side. The client lives alone but receives regular assistance from her daughter and son, who both live within 10 miles. Which of the
following actions should the nurse take to assess the client’s safety risk? Select all that apply. Assessing the client’s visual acuity Observing the client’s gait and posture Evaluating the client’s muscle strength Looking for any hazards in the home environment Asking a family member to move in with the client until her recovery is complete Requesting that the client transfer to an assisted living environment for at least 1 month 95. Which of the following statements reflect the principles of sterile technique? Select all that apply. The edge of a sterile field and a border 1 inch (2.5 cm) inward is unsterile. If a package is not labeled as sterile, it should be considered unsterile. Sterile objects that come in contact with unsterile objects are to be considered contaminated.
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- Fall '19