Question

A nurse a long-term care facility is admitting a client who has dementia. Which of the following actions should the nurse take to reduce the risk for the client injury?

Answer 1

Correct Answers:

Assist the client to the toilet frequently.

Rationale :

💎Clients with dementia have impaired memory, judgment, and sometimes mobility, increasing their risk for falls and injury.

💎Frequent toileting addresses common triggers for wandering and unsafe attempts to get out of bed, such as urinary urgency.

💎This proactive approach helps prevent falls, reduces incontinence episodes, and promotes dignity.

💎It also decreases nighttime restlessness, which can lead to confusion and injury.

💎Coupling this with other safety interventions—such as adequate lighting, uncluttered pathways, and orientation cues—maximizes safety in long-term care settings.

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Answer 2

Correct Answers

Blank 1 Correct Option: arterial obstruction
Blank 2 Correct Option: color and temperature of right lower extremity

Rationale :

💎After a right femoral artery cardiac catheterization, the most concerning post‑procedure complication is arterial obstruction (from thrombus, embolus, arterial spasm, or hematoma compressing the artery).

💎The infant’s right pedal pulse is weaker than the left, with pallor and the leg cooler to the touch—classic indicators of impaired arterial perfusion rather than simple venous issues or hypovolemia.

💎In arterial compromise, nurses prioritize the 5 Ps of ischemia—Pain, Pallor, Pulselessness/weak pulse, Paresthesia, Paralysis (late)—and compare bilateral pulses, color, temperature, capillary refill, and movement.

💎Although a small amount of drainage is noted on the dressing and the BP is slightly lower than baseline, stable H/H and normal capillary refill elsewhere make hemorrhagic shock less likely; likewise, glucose 60 mg/dL with D5/0.9% infusing is addressed but does not explain the unilateral limb findings.

💎The appropriate response is urgent notification of the provider, maintaining limb alignment, frequent neurovascular checks (q15 min initially), and preparation for possible anticoagulation or vascular intervention to prevent limb ischemia.

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Answer 3

Correct Answers:

Avoid long car rides.
Notify dentist of valvuloplasty before appointments.
Report bruising to your provider.
Maintain a daily weight chart.
Take anticoagulant medications at the same time each day.

Rationale :

Notify dentist of valvuloplasty before appointments

💎Clients who have undergone a valvuloplasty are at risk for infective endocarditis during invasive dental procedures due to potential bacteremia.

💎Notifying the dentist ensures they can determine if antibiotic prophylaxis is indicated to prevent valve infection.

💎The American Heart Association guidelines recommend prophylaxis for certain high-risk cardiac conditions, especially those involving prosthetic material or valve repairs.

💎This is a lifelong preventive measure in many cases to protect cardiovascular health.

Report bruising to your provider

💎The client is being discharged on warfarin, an anticoagulant that increases the risk of bleeding.

💎Easy bruising, nosebleeds, blood in urine or stools, or prolonged bleeding should be reported immediately.

💎These can indicate excessive anticoagulation or elevated INR values.

💎 Early reporting allows for dosage adjustment and prevention of severe hemorrhage.

Maintain a daily weight chart

💎The client’s history of shortness of breath and ankle edema suggests heart failure as a possible comorbidity.

💎Daily weights help detect fluid retention early, allowing timely diuretic adjustment.

💎A sudden gain of >2 lb (0.9 kg) in 24 hr or >5 lb (2.3 kg) in a week should be reported to the provider.

💎This is an essential part of self-monitoring in cardiac patients.

Take anticoagulant medications at the same time each day

💎Warfarin should be taken consistently at the same time daily to maintain steady therapeutic levels and avoid INR fluctuations.

💎Consistency minimizes the risk of clot formation or excessive bleeding.

💎Clients should also be educated about avoiding sudden dietary changes that affect vitamin K intake.

💎Keeping a set schedule improves adherence and effectiveness of therapy.

Avoid long car rides

💎Long periods of immobility increase the risk of deep vein thrombosis (DVT), especially in clients on anticoagulation therapy post-cardiac procedure.

💎If travel is unavoidable, frequent breaks to walk and stretch should be taken.

💎Movement promotes venous return and reduces clot formation risk.

💎This is particularly important after procedures involving femoral access and in patients with cardiac disease.

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Answer 4

Correct Answers:

Instruct the client to perform diaphragmatic breathing.
Assess the client’s breath sounds.
Perform chest percussion and vibration.

Rationale :

Instruct the client to perform diaphragmatic breathing.

Diaphragmatic breathing helps maximize alveolar ventilation and promote efficient gas exchange in clients with chronic respiratory issues such as COPD.
This technique reduces the work of breathing, improves oxygenation, and helps expel trapped air from the lungs.
Teaching the client to combine diaphragmatic breathing with pursed-lip breathing can further reduce air trapping and ease shortness of breath.

Assess the client’s breath sounds.

Frequent auscultation is essential to monitor for changes such as increased wheezing, crackles, or diminished sounds.
This helps evaluate treatment effectiveness after interventions like bronchodilators or oxygen therapy.
Early detection of worsening airway obstruction or fluid accumulation allows for timely interventions.

Perform chest percussion and vibration.

Chest physiotherapy techniques such as percussion and vibration mobilize secretions in the airways, making it easier to expectorate mucus.
This is particularly beneficial for clients with productive cough and wheezing, as seen in this case.
Removing excess secretions helps improve ventilation, reduce infection risk, and enhance overall respiratory function.

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Answer 5

Correct Answers:

Give the dose 60 min.

Rationale :

💎Vancomycin should be administered slowly over at least 60 minutes to reduce the risk of Red Man Syndrome, a histamine-mediated reaction characterized by flushing, rash, and hypotension.

💎Rapid infusion increases the likelihood of severe hypotension, flushing, and in some cases, anaphylactoid reactions.

💎A controlled infusion rate ensures the drug distributes more gradually into the bloodstream, reducing mast cell degranulation.

💎This practice also helps protect renal function, as vancomycin is nephrotoxic, and preventing acute infusion reactions supports safer therapy.

💎Nurses should also monitor vital signs during infusion to detect early signs of adverse reactions.

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Answer 6

Correct Answers:

Hyperventilate the client with 100% oxygen before suctioning.

Rationale :

🔷Preoxygenation with 100% oxygen for 30–60 seconds before suctioning prevents hypoxemia during the procedure.

🔷Suctioning temporarily removes oxygen from the airway, so increasing oxygen reserves beforehand maintains adequate tissue perfusion.

🔷This practice is critical for clients with a new tracheostomy, as they have a higher risk of respiratory compromise.

🔷Hyperventilation also helps wash out CO₂ and improves oxygen saturation prior to the suction pass.

🔷Ensuring adequate oxygenation before suctioning can reduce complications such as bradycardia and arrhythmias caused by hypoxia.

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Answer 7

Correct Answers:

Check the functioning of the suction equipment.

Rationale :

🟢 The first step in troubleshooting an NG tube that is not draining is verifying suction equipment function to rule out a mechanical issue.

🟢 If the suction machine is off, disconnected, or set incorrectly, gastric contents will not be aspirated effectively.

🟢 Starting with equipment assessment follows the nursing process priority—address the most immediate and easily correctable cause first.

🟢 This step avoids unnecessary and potentially uncomfortable interventions like tube repositioning or irrigation.

🟢 Proper suction ensures continuous gastric decompression, which helps relieve distension, prevent aspiration, and promote comfort.

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Answer 8

Correct Answers:

Instill erythromycin ointment into the newborn's eyes.

Rationale :

🔴Erythromycin ophthalmic ointment is routinely administered to all newborns to prevent ophthalmia neonatorum, which can result from maternal gonorrhea or chlamydia.

🔴This prophylactic treatment helps protect the cornea from ulceration and blindness caused by untreated infection.

🔴The ointment is applied within the first 1–2 hours after birth, as mandated in many public health guidelines.

🔴It is effective even if the mother was untreated prior to delivery, ensuring the infant is protected from vertical transmission.

🔴This intervention is non-invasive, well tolerated, and essential for neonatal eye health.

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Answer 9

Correct Answers:

Improved short-term memory

Rationale :

🟡Donepezil is a cholinesterase inhibitor that enhances acetylcholine levels in the brain, improving communication between neurons.

🟡Its primary therapeutic effect is improving cognitive function, especially short-term memory in clients with Alzheimer’s disease or dementia.

🟡This improvement helps clients maintain independence in daily activities for a longer period.

🟡The medication works best in the early to moderate stages of cognitive decline.

🟡Regular evaluation of memory function helps determine ongoing medication effectiveness.

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Answer 10

Correct Answers:

Absence of eclampsia

Rationale :

🔵Magnesium sulfate is administered to clients with preeclampsia to prevent seizures, which is the defining feature of eclampsia.

🔵It acts as a central nervous system depressant, reducing neuromuscular transmission and vasospasm.

🔵Monitoring for the absence of seizures is the primary measure of therapeutic effectiveness.

🔵Additional monitoring includes deep tendon reflexes, respiratory rate, and urine output to avoid magnesium toxicity.

🔵Prevention of seizure activity protects both maternal and fetal outcomes.

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RN Comprehensive 2023(2025August Edition)

No.

1 :
A nurse a long-term care facility is admitting a client who has dementia. Which of the following actions should the nurse take to reduce the risk for the client injury?

2 :
A nurse is caring for a 3-month-old infant.

Correct Answers

3 :
A nurse is caring for a client in an acute care facility.

Answer Options

4 :
Patient's data.

Answer Options

5 :
A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin?

6 :
A nurse is caring for a client who has a new tracheostomy. Which of the following actions should the nurse take when suctioning the client undergoing tracheostomy?

7 :
A nurse is caring for a client who has a nasogastric (NG) tube in place for gastric decompression and notes that the tube is not draining. Which of the following steps should the nurse take first?

8 :
A nurse is planning care for a client who in labor and has gonorrhea. Which of the following actions should the nurse in the take?

9 :
A nurse in a long-term care facility is providing care for a client who has been receiving donepezil. Which of the following findings indicates that the medication is effective?

10 :
A nurse assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?

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RN Comprehensive 2023(2025August Edition)

No.

1 : A nurse a long-term care facility is admitting a client who has dementia. Which of the following actions should the nurse take to reduce the risk for the client injury?

2 : A nurse is caring for a 3-month-old infant.

Correct Answers

3 : A nurse is caring for a client in an acute care facility.

Answer Options

4 : Patient's data.

Answer Options

5 : A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin?

6 : A nurse is caring for a client who has a new tracheostomy. Which of the following actions should the nurse take when suctioning the client undergoing tracheostomy?

7 : A nurse is caring for a client who has a nasogastric (NG) tube in place for gastric decompression and notes that the tube is not draining. Which of the following steps should the nurse take first?

8 : A nurse is planning care for a client who in labor and has gonorrhea. Which of the following actions should the nurse in the take?

9 : A nurse in a long-term care facility is providing care for a client who has been receiving donepezil. Which of the following findings indicates that the medication is effective?

10 : A nurse assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?

1 :
A nurse a long-term care facility is admitting a client who has dementia. Which of the following actions should the nurse take to reduce the risk for the client injury?

2 :
A nurse is caring for a 3-month-old infant.

3 :
A nurse is caring for a client in an acute care facility.

4 :
Patient's data.

5 :
A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin?

6 :
A nurse is caring for a client who has a new tracheostomy. Which of the following actions should the nurse take when suctioning the client undergoing tracheostomy?

7 :
A nurse is caring for a client who has a nasogastric (NG) tube in place for gastric decompression and notes that the tube is not draining. Which of the following steps should the nurse take first?

8 :
A nurse is planning care for a client who in labor and has gonorrhea. Which of the following actions should the nurse in the take?

9 :
A nurse in a long-term care facility is providing care for a client who has been receiving donepezil. Which of the following findings indicates that the medication is effective?

10 :
A nurse assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?