Rationale: Because the nurse can only stand on one side of the bed, bed rails should be
up on the opposite side to ensure that the client does not fall
... [Show More] out of bed. Option A can
cause client injury to the skin or joint. Options C and D are useful techniques while
turning a client but have less priority in terms of safety than use of the bed rails. -
ANSWERS--When turning an immobile bedridden client without assistance, which
action by the nurse best ensures client safety?
A. Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly.
B
Rationale: Careful handwashing technique is the single most effective intervention for
the prevention of contamination to all clients. Option A reverses the hypovolemia that
initially accompanies burn trauma but is not related to decreasing the proliferation of
infective organisms. Options C and D are recommended by various burn centers as
possible ways to reduce the chance of infection. Option B is a proven technique to
prevent infection. -ANSWERS--The nurse identifies a potential for infection in a client
with partial-thickness (second-degree) and full-thickness (third-degree) burns. What
intervention has the highest priority in decreasing the client's risk of infection?
A. Administration of plasma expanders
B. Use of careful handwashing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns
A
Rationale: Long-term protein deficiency is required to cause significantly lowered serum
albumin levels. Albumin is made by the liver only when adequate amounts of amino
acids (from protein breakdown) are available. Albumin has a long half-life, so acute
protein loss does not significantly alter serum levels. Option B is a serum protein with a
half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C
and D are not clinical measures of protein malnutrition. -ANSWERS--The nurse is
aware that malnutrition is a common problem among clients served by a community
health clinic for the homeless. Which laboratory value is the most reliable indicator of
chronic protein malnutrition?
A. Low serum albumin level
B. Low serum transferrin level
C. High hemoglobin level
D. High cholesterol level
C
Rationale: The surgeon should be informed immediately that the permit is not signed. It
is the surgeon's responsibility to explain the procedure to the client and obtain the
client's signature on the permit. Although the nurse can witness an operative permit, the
procedure must first be explained by the health care provider or surgeon, including
answering the client's questions. The client's questions should be addressed before the
permit is signed. -ANSWERS--In completing a client's preoperative routine, the nurse
finds that the operative permit is not signed. The client begins to ask more questions
about the surgical procedure. Which action should the nurse take next?
A. Witness the client's signature to the permit.
B. Answer the client's questions about the surgery.
C. Inform the surgeon that the operative permit is not signed and the client has
questions about the surgery.
D. Reassure the client that the surgeon will answer any questions before the anesthesia
is administered. [Show Less]