A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first?

Peripheral pulses

Comfort level

Skin integrity

Elimination needs

Answer and Explanation

The Correct Answer is A

When caring for a client who has restraints, the nurse should follow the ABCDE priority-setting framework and assess airway, breathing, circulation, disability, and exposure first. Peripheral pulses are an indicator of circulation and should be assessed first to ensure adequate blood flow to the extremities. Comfort level, skin integrity, and elimination needs are also important assessments but are not as high priority as circulation.

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Correct Answer is D

Explanation

A. "I will put some lubricant on the flat end of the suppository.": It is generally not necessary to use lubricant on the suppository. If lubrication is needed, it should be applied sparingly to the rounded end, not the flat end.

B. "I will lie on my left side to insert the suppository.": The recommended position for inserting a vaginal suppository is usually lying on your back with your knees bent or standing with one foot elevated, not lying on the left side.

C. “I can discontinue the medications once my symptoms are gone.": This is incorrect. It is important to complete the full course of medication to ensure the infection is fully treated, even if symptoms improve before finishing the medication.

D. "I will place the suppository as far inside my vagina as I can reach.”: This statement is correct. The suppository should be inserted high into the vagina to ensure it is placed correctly and will dissolve properly to treat the infection.

A. Determine the client's reading ability. B. Explain the techniques of esophageal speech. C. Review the use of an artificial larynx with the client. D. Schedule a support session for the client.

Correct Answer is C

Explanation

A total laryngectomy is a surgical procedure that removes the entire larynx (voice box) and separates the airway from the mouth, nose and esophagus. The client will have a permanent tracheostomy (an opening in the neck) and will not be able to speak normally. An artificial larynx is a device that produces sound by vibrating against the neck or cheek and allows the client to communicate orally. The nurse's priority intervention is to review the use of an artificial larynx with the client before surgery to facilitate postoperative communication and reduce anxiety.

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A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client about the administration of clotrimazole vaginal suppositories. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

Correct Answer is C

Explanation

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