The nurse performs a home safety survey for an older adult. Click to specify the findings that require intervention by the nurse.
Rationale:
Scatter rugs at the end of the stairs, a smoke detector present without a battery, and an extension cord covered with an anti-skid area rug require intervention by the nurse.
A scatter rug at the stairs poses a tripping hazard, especially for older adults. A smoke detector without a battery cannot alert residents to fire hazards. An extension cord covered by a rug increases the risk of electrical fires.
C: Stairs present with sturdy hand rails. Sturdy handrails enhance safety and support for older adults navigating stairs, reducing the risk of falls.
D: New light fixtures installed and connected in a grounded electrical outlet. Properly installed light fixtures in grounded outlets are safe and contribute positively to home safety.
F: Unlabeled household chemicals under the sink. Unlabeled chemicals pose a poisoning risk, but the presence of these chemicals alone does not indicate immediate danger requiring nurse intervention.
G: Fire extinguisher present 30 feet from the stove. While a fire extinguisher is essential, its distance from the stove may hinder quick access during emergencies, but not necessarily require immediate intervention.
The nurse works on a medical-surgical unit and is responsible for assessing the client's vital signs. Which of the following clients can have their temperature measured orally? Select all that apply.
Rationale:
B, C, D
Clients B, C, and D are appropriate for oral temperature measurement as they do not have conditions affecting the oral cavity, swallowing, or require alternative methods due to recent surgery or severe symptoms. Each can safely provide an accurate temperature reading without risk of discomfort or inaccuracy.
A: A 61-year-old woman who had oral surgery. Recent oral surgery may lead to discomfort, swelling, or potential complications that prevent accurate temperature measurement through the mouth.
E: A 6-year-old client with a sore throat and difficulty swallowing. Difficulty swallowing indicates a risk of choking or distress, making oral temperature measurement inappropriate and unsafe for this child.
The nurse is applying soft wrist restraints to a client who is violent towards the nursing staff. Which actions by the nurse are appropriate? Select all that apply.
Rationale:
D: Informs the client of the behavior necessary to demonstrate to end the restraints. This action promotes understanding and compliance, empowering the client to regain control and potentially reduce aggression, fostering a therapeutic environment.
E: Ensures two fingers can be placed under each restraint. This practice ensures proper circulation and comfort for the client, adhering to safety protocols and preventing potential injury or complications from overly tight restraints.
A: Places a pair of scissors at the bedside for emergent discontinuation. Leaving sharp objects within reach poses a significant risk to the client's safety, contradicting the purpose of applying restraints.
B: Positions the client supine after applying both wrist restraints. This position may increase the risk of injury or discomfort, as it can restrict movement and lead to potential respiratory complications.
C: Releases both restraints at the same time, every two hours. Releasing restraints simultaneously could result in a lack of control over the client's behavior, endangering both staff and patient safety during the process.
The nurse needs to assess the use of complementary and alternative medicine (CAM) because:
Rationale:
C: CAM therapy could interact with prescription and over-the-counter medications. Understanding these interactions is essential for ensuring patient safety and optimizing treatment outcomes, as some CAM therapies may alter the effectiveness or increase side effects of conventional medications.
A: Patients should be warned that most CAM therapies are potentially dangerous. Not all CAM therapies pose risks; many are safe and beneficial when used appropriately, requiring a more nuanced understanding.
B: Additional treatment may not be needed if the patient is using CAM. This does not consider that CAM is often used alongside conventional treatments, highlighting the need for comprehensive assessment.
D: Most CAM therapies are essentially ineffective. Many CAM therapies have shown benefits for various conditions, suggesting that effectiveness varies widely and should not be dismissed outright without proper evaluation.
The nurse is inserting an indwelling urinary catheter in a male client. It would be appropriate for the nurse to inflate the catheter's balloon when
Rationale:
C: After advancing to the point of bifurcation. Inflating the catheter's balloon at this stage ensures proper placement and secures it within the bladder, preventing potential complications and ensuring patient safety.
A: Meeting resistance. Inflating the balloon at this moment may cause harm or injury, as resistance indicates that the catheter may not be correctly positioned.
B: As soon as urine is observed in the tubing. Observing urine does not guarantee proper catheter placement; inflation should occur only when the catheter is fully advanced.
D: After fully advancing the length of the catheter. While important, inflation should specifically occur at the bifurcation point to ensure optimal positioning within the bladder before securing it.
The nurse is planning a staff development conference about ways to prevent the transmission of the hepatitis C virus to healthcare workers. It would be appropriate for the nurse to cover which topic?
Rationale:
Healthcare workers should cover how to dispose of sharps safely. Proper disposal of sharps minimizes the risk of needlestick injuries, significantly reducing the likelihood of hepatitis C virus transmission in healthcare settings.
A: How to obtain the HCV vaccine. No vaccine currently exists for hepatitis C, rendering this topic irrelevant for preventing transmission among healthcare workers.
C: How to dispose of urine and feces for those with HCV. While important, this topic does not directly address the primary transmission route associated with healthcare workers.
D: Isolation precautions for individuals with HCV. Isolation is not necessary for HCV, as the virus primarily spreads through blood, making this option less relevant for staff development.
The nurse is educating the parents of a child who plans on riding their bicycle. Which statements, if made by the parents, indicate effective understanding?
Rationale:
B: I should instruct my child to walk their bike through busy intersection crosswalks. This statement reflects an understanding of safety protocols, emphasizing caution in high-traffic areas and protecting the child from potential accidents while navigating complex intersections.
A: I should tell my child to ride their bike against the traffic pattern. Riding against traffic increases the likelihood of collisions and reduces visibility to drivers, posing significant safety risks.
C: Wearing a helmet is only necessary when my child is riding near a busy intersection. Helmets are crucial for all cycling activities, not just in high-traffic areas, to prevent head injuries.
D: My child can ride their bike barefoot as long as it's short distances. Riding barefoot poses risks such as foot injuries, regardless of distance, compromising the child’s safety and comfort while cycling.
The nurse observes unlicensed assistive personnel (UAP) give a bed bath using 4% chlorhexidine (CHG) wipes. Which observation requires follow-up?
Rationale:
The UAP rinses the skin after bathing with the CHG solution.
Rinsing the skin after using chlorhexidine wipes can diminish the antiseptic's effectiveness, which is crucial for infection prevention. Proper use involves allowing the solution to remain on the skin to maximize its antimicrobial action, particularly in vulnerable patients.
A: The UAP uses one wipe for washing each major body part. This practice ensures thorough cleaning without cross-contamination, maintaining hygiene standards during the bed bath process.
C: The UAP washes the client's face with warm water and mild soap. Using mild soap and warm water for the face is appropriate, as it helps prevent irritation while ensuring cleanliness.
D: The UAP allows the CHG solution to dry on the client's skin. Allowing chlorhexidine to air dry is acceptable, as it promotes antiseptic properties and ensures optimal effectiveness against potential pathogens.
The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure?
Rationale:
Suction equipment should be at the bedside following the cheiloplasty. This ensures that any excess secretions or potential airway obstructions can be promptly managed, safeguarding the infant's respiratory status and comfort post-surgery.
A: Nasogastric tube (NGT) This device is not essential immediately after a cheiloplasty, as the focus is on airway management rather than feeding, which can be addressed later.
B: Bottle of sterile water While sterile water is important for hydration, it does not directly address immediate post-operative needs related to respiratory management after a cheiloplasty.
D: Tracheostomy This invasive procedure is not a routine necessity after a cheiloplasty; it is reserved for severe airway compromise, which is unlikely in this context.
The nurse plans to care for a client admitted with Haemophilus influenzae, type b Meningitis. When caring for this client, the nurse should gather which appropriate personal protective equipment (PPE)?
Rationale:
C: Surgical mask. This option is appropriate as Haemophilus influenzae type b meningitis is transmitted through respiratory droplets, making a surgical mask essential for protecting both the client and healthcare providers.
A: Boot (shoe) covers. These do not provide protection against respiratory droplets and are irrelevant in the context of preventing the spread of meningitis.
B: Face shield. While beneficial for eye protection, a face shield does not adequately prevent droplet transmission, which is crucial in managing meningitis cases.
D: Gown. Though a gown offers protection from direct contact, it does not address the airborne risk posed by respiratory droplets in cases of meningitis.
The occupational health nurse assesses a health care worker's purified protein derivative (PPD) test and measures 11 mm of induration. The nurse should interpret this finding as
Rationale:
Further testing is required. An induration of 11 mm in a PPD test indicates a positive reaction, yet additional assessment is necessary to confirm active infection and address potential exposure risks.
A: A confirmatory test result for pulmonary tuberculosis. An 11 mm induration does not definitively confirm active tuberculosis; further diagnostic evaluations are essential to establish the presence of the disease.
B: A false-negative test result. The measurement indicates a positive response, meaning it is not a false-negative; rather, it suggests the need for additional evaluation to understand the results better.
C: The healthcare worker requires immediate isolation using airborne isolation precautions. Isolation is not warranted based solely on an induration of 11 mm; further investigation is needed before determining isolation measures.
The nurse observes a fire in a client's room. The nurse should take which initial action?
Rationale:
Rescue the client. Prioritizing the safety of the client is crucial in a fire situation; immediate evacuation reduces the risk of injury or death, ensuring their well-being before addressing the fire itself.
B: Extinguish the fire. Tackling the flames should never come before ensuring the client’s safety, as this could lead to dangerous situations for both the nurse and the client.
C: Activate the fire alarm. While notifying others is important, the immediate focus must be on protecting the client from harm, which takes precedence over alerting the facility.
D: Place a linen blanket over the fire. This action could be ineffective or even dangerous, as it may not extinguish the flames properly and diverts attention away from the client's safety.
The nurse is reviewing the vital signs of a client admitted with atrial fibrillation. The client's vital signs are: T 37.5°C (99.6°F), P 88 and irregular, RR 20, BP 90/56 mmHg, pulse oximetry reading 96% on room air. The nurse should immediately address which vital sign?
Rationale:
Blood pressure. The client's blood pressure reading of 90/56 mmHg indicates hypotension, which is critical in a patient with atrial fibrillation, as it can lead to decreased perfusion and potential complications.
A: Temperature Elevated temperature is not significantly alarming in the context of atrial fibrillation and does not require immediate intervention unless there are additional concerns related to infection or other complications.
C: Respiratory rate A respiratory rate of 20 breaths per minute is within an acceptable range for many patients, particularly in the context of atrial fibrillation, and does not necessitate urgent attention.
D: Pulse While the pulse is irregular, a rate of 88 beats per minute is not dangerously low or high, and thus does not require immediate intervention compared to the blood pressure concern.
The nurse preceptor is observing a newly hired nurse care for a client with a tracheostomy. Which of the following actions by the newly hired nurse would require follow-up by the observing nurse preceptor?
Rationale:
Applying suction in a twirling motion while removing the catheter is inappropriate. This technique can cause trauma to the trachea and increase the risk of complications such as bleeding or airway obstruction, making it a crucial action that requires follow-up.
B: Inflates the tracheostomy's cuff with 5 mL of air prior to suctioning. This action ensures the cuff is adequately inflated to prevent aspiration during suctioning, promoting client safety and effective procedure.
C: Preoxygenates the client with 100% oxygen prior to suctioning. This practice optimizes oxygenation, reducing the risk of hypoxia during the suctioning process, and is a standard part of tracheostomy care.
D: Provides mouth care after suctioning the tracheostomy. This action is beneficial for maintaining oral hygiene and preventing infection, and it does not pose a risk to the client’s airway.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 4 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client with progressive multiple sclerosis.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Obtain a referral for occupational therapy for fatigue and energy conservation training
B
Promote rest by encouraging daytime napping over consistent nighttime sleep
C
Encourage the client to walk to the mailbox at midday for sun exposure
D
Instruct the client to increase fluid intake with caffeinated beverages
E
Obtain an order for physical therapy for home mobility and coordination evaluation
F
Educate the client on the early signs of cystitis and the importance of completing antibiotics
G
Educate the client to wear slippers while walking inside
Rationale:
Obtain a referral for occupational therapy for fatigue and energy conservation training. This intervention is essential as clients with progressive multiple sclerosis often experience fatigue, and occupational therapy can provide strategies to manage energy levels effectively, enhancing daily functioning and quality of life.
B: Promote rest by encouraging daytime napping over consistent nighttime sleep. Prioritizing inconsistent sleep patterns disrupts the natural circadian rhythm, potentially worsening fatigue and limiting overall restorative rest.
C: Encourage the client to walk to the mailbox at midday for sun exposure. While sunlight is beneficial, pushing physical activity during fatigue can lead to exhaustion rather than promoting well-being.
D: Instruct the client to increase fluid intake with caffeinated beverages. Caffeine can lead to dehydration, which is particularly detrimental for individuals with multiple sclerosis, negatively affecting their health.
E: Obtain an order for physical therapy for home mobility and coordination evaluation. This option is valid and beneficial as it addresses mobility issues and coordination challenges common in progressive multiple sclerosis, enhancing safety and independence.
F: Educate the client on the early signs of cystitis and the importance of completing antibiotics. This intervention is appropriate as it aids in preventing complications from urinary tract infections, which can exacerbate symptoms of multiple sclerosis.
G: Educate the client to wear slippers while walking inside. This option is useful in preventing falls and providing comfort, which is vital for maintaining safety and stability within the home environment.
The nurse is preparing a client for a clinical breast exam by the physician. To facilitate an effective exam, the nurse should position the client
Rationale:
Supine, with the arm on the side raised behind the head, and a small pillow under the shoulder. This position allows for optimal access to the breast tissue, promoting thorough examination by the physician while ensuring the client’s comfort and stability during the procedure.
A: Supine with arms at the side and a pillow under both knees. This positioning restricts access to breast tissue, making the clinical exam less effective due to limited range of motion.
B: Left lateral with the head resting on a pillow and the arm over the head. This position is not suitable for a breast exam, as it impedes proper access to the breast area.
C: Sitting forward with a pillow behind the shoulder blades with hands on the hips. This posture does not facilitate an effective breast examination, as it does not provide adequate exposure and access to the breasts.
Which of the following statements about security in healthcare environments is accurate?
Rationale:
All members of the healthcare facility must have education and training relating to security in the facility. This ensures that each employee understands their role in maintaining safety and is prepared to address security challenges effectively. Comprehensive training fosters a culture of vigilance and empowers staff to respond appropriately to potential threats.
A: Healthcare facilities must have egress alarms on all doors, except client doors, to maintain security within the facility. This statement is overly specific and does not encompass broader security training responsibilities for all staff members.
C: Members of the healthcare facility who do not have clinical access do not need education and training relating to security in the facility. Security awareness is essential for everyone, regardless of their specific role within the healthcare setting.
D: Members of the healthcare facility who have only clerical roles do not need education and training relating to security in the facility. Clerical staff play critical roles in maintaining security and must be trained to recognize and report potential risks.
The nurse is caring for a client with a recently fractured left tibia who is grimacing and slightly diaphoretic. The nurse should initially
Rationale:
C: Assess the client for pain.
Assessing the client's pain is the priority, as grimacing and diaphoresis indicate potential distress. Understanding the severity and nature of the pain will guide appropriate interventions and ensure the client receives the necessary care promptly.
A: Perform range of motion with the client's left leg.
Initiating range of motion exercises without evaluating pain could exacerbate the injury and increase discomfort, neglecting the immediate need for pain assessment and management.
B: Obtain the client's temperature.
Taking the client's temperature does not address the immediate signs of pain and discomfort. The focus should be on evaluating and managing the pain rather than checking for fever.
D: Administer prescribed oxycodone-acetaminophen.
Administering medication without prior assessment might overlook critical details about the client's pain level, potentially leading to inadequate pain management or delayed treatment for other underlying issues.
The nurse is reviewing the laboratory results of a client scheduled for surgery. Which of the following should be reported to the primary health care provider (PHCP)?
Rationale:
A: Glycosylated hemoglobin (HbA1c) of 7.2% indicates poor long-term glucose control, but it does not present an immediate risk for surgery compared to elevated INR levels, which could lead to bleeding complications.
B: International Normalized Ratio (INR) of 3.5 signifies a significantly increased risk of bleeding during surgery, necessitating urgent communication with the PHCP to manage anticoagulation therapy and ensure patient safety.
C: Hematocrit (Hct) of 42% falls within the normal range for both males and females, indicating no immediate concern and does not require reporting to the PHCP prior to surgery.
D: Blood urea nitrogen (BUN) level of 5 is below the normal range but is not a critical finding that would necessitate immediate reporting to the primary health care provider before surgery.
The nurse performs a head-to-toe assessment on an assigned client. Which of the following client findings are examples of subjective data? Select all that apply.
Rationale:
The client reports feeling nauseated.
Subjective data encompasses information conveyed by the client about their feelings and experiences. Options A, C, D, and E reflect personal perceptions and sensations, making them subjective, while the focus is on individual reports rather than observable facts.
B: The client's lower extremities are swollen. This describes an observable physical condition, which constitutes objective data rather than subjective personal experiences or perceptions expressed by the client.
F: The client vomits twice after eating dinner. This depicts an observable event, representing objective data. It is a factual occurrence rather than a personal interpretation of feelings or sensations.
Item 1 of 1 • Assessment
Neurological: Alert and Oriented x 4; anxious affect
Cardiovascular: S1, S2 heart tones; all peripheral pulses palpable; no edema
Gastrointestinal: Distended abdomen; absent bowel sounds; hiccups; reports persistent nausea
Genitourinary: Denies dysuria; voiding every 3-4 hours with straw-colored urine
Musculoskeletal: Full range of motion in all extremities; steady gait
Integumentary: Incision is approximated; moderate dry sanguineous drainage was noted on the dressing.
Pain: Reports incision pain as a 3 based on a scale of 0-10.
• Vital Signs
Blood Pressure 119/75 mm Hg
Temperature 99° F (37° C)
Heart rate 90/min
Respiratory rate 17 breaths per minute
Oxygen saturation 97% on room air
The nurse is caring for a client two days postoperative following a partial colectomy.Complete the sentence below from the list of options: The client is at risk of developing --------------based on the client’s------------------------
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
paralytic ileus
B
wound infection
C
intractable pain
D
integumentary assessment
E
pain assessment
F
gastrointestinal assessment
Rationale:
The client is at risk of developing paralytic ileus based on the client’s gastrointestinal assessment.
Paralytic ileus is a common postoperative complication, particularly following abdominal surgery like a partial colectomy. The client’s distended abdomen and absent bowel sounds indicate a high probability of gastrointestinal motility issues, necessitating careful monitoring and intervention to prevent further complications.
B: wound infection The assessment shows no signs of infection, as the incision is approximated and drainage is moderate, indicating proper healing rather than an infection risk.
C: intractable pain Pain is reported as a manageable 3 on a scale of 0-10, suggesting that the client does not experience severe or unmanageable pain at this time.
D: integumentary assessment The integumentary assessment shows that the incision is approximated, which indicates no immediate concerns or complications related to skin integrity that would pose a risk.
E: pain assessment The pain assessment indicates that the client’s pain level is stable and not escalating, suggesting that pain is not a significant risk factor at this time.
The nurse is caring for a post-operative client at high risk for pneumonia. Which intervention would be most effective in the prevention of this complication?
Rationale:
Early ambulation is the most effective intervention in preventing pneumonia for a post-operative client at high risk. This activity enhances lung expansion, promotes secretion clearance, and increases overall respiratory function, significantly reducing the risk of respiratory complications.
A: Passive range of motion does not directly engage the respiratory system and lacks the active participation needed to enhance lung capacity and prevent pneumonia effectively.
B: Sequential compression devices (SCDs) primarily target venous thromboembolism prevention and do not contribute to improving lung function or reducing the risk of pneumonia post-operatively.
D: Prophylactic antibiotics can prevent infection but do not address the underlying respiratory mechanics, making them less effective for pneumonia prevention compared to active mobilization strategies.
The nurse observes a student inserting an indwelling urinary catheter into a female client. Which action by the student requires follow-up by the nurse? The student
Rationale:
The student applies clean gloves to cleanse the perineal area with soap and water. This action requires follow-up because proper technique necessitates the use of sterile gloves to maintain aseptic conditions during catheter insertion.
B: Asks the client to bear down as the catheter is slowly inserted through the urethral meatus. This action helps facilitate the catheter's passage, promoting comfort and reducing resistance during insertion.
D: Secures the catheter tubing to the inner thigh. This is an appropriate practice to prevent tension on the catheter and ensure patient comfort while maintaining proper positioning of the tubing.
E: Attaches the drainage bag to the side rails of the bed. This practice can lead to potential complications, such as backflow of urine, which may cause infections or other issues.
Which hazardous gas can be identified in the home with a simple and relatively inexpensive monitor and alarm similar to a smoke alarm?
Rationale:
Carbon monoxide can be identified in the home with a simple and relatively inexpensive monitor and alarm similar to a smoke alarm.
Carbon monoxide is colorless and odorless, making it difficult to detect without specialized equipment. A monitor and alarm are essential for alerting residents to dangerous levels, ensuring safety and preventing poisoning in enclosed spaces where this gas may accumulate.
A: Ozone presents health risks, but detection typically requires specialized equipment beyond simple home monitors. It's not commonly found indoors at harmful levels compared to carbon monoxide.
B: Nitrous oxide is primarily associated with medical and industrial uses, not typical household environments. Detection methods are specialized and not aligned with standard home safety monitoring.
D: Carbon dioxide occurs naturally in the home and is not considered hazardous at low levels. Monitors for carbon dioxide are less common and not typically urgent for safety.
The nurse supervises a student assisting a client with left-sided weakness in performing activities of daily living. Which action by the student nurse requires the nurse to intervene? The student nurse
Rationale:
The student nurse places the wheelchair as close to the bed as possible on the client's affected (weaker) side. This action is inappropriate because it increases the risk of falls and makes transferring to the wheelchair more difficult for the client with left-sided weakness.
A: Puts the client's affected (weaker) arm in the shirt's sleeve first. This method ensures that the weaker side is dressed appropriately, promoting independence and comfort for the client during dressing.
B: Places shoes with velcro straps on the client's feet. Velcro shoes are a practical choice, facilitating easier and quicker dressing for clients with limited mobility or strength in their extremities.
D: Places the hairbrush in the client's unaffected (stronger) hand. This approach allows the client to utilize their stronger side to perform grooming tasks, fostering independence and encouraging self-care despite weakness on the left side.
The nurse is part of a committee tasked with reducing medical errors in the nursing unit. Which of the following recommendations should the nurse make to the committee? Select all that apply.
Rationale:
Nurse-to-nurse bedside handoff reporting, handoff reporting using the ISBAR framework, ensuring staff take uninterrupted breaks, and increasing lighting around medication dispensing machines are crucial recommendations for reducing medical errors. These strategies promote effective communication, enhance staff well-being, and improve the overall safety of medication administration.
A: Increase the number of verbal orders given from primary healthcare providers. Verbal orders can lead to miscommunication and misunderstandings, increasing the potential for medical errors within the nursing unit.
E: Increase the lighting around the medication dispensing machines. While better lighting is beneficial, it does not directly address communication or workflow issues that are critical in reducing medical errors.
Which of the following clients would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain?
Rationale:
B: A 56-year-old client with a below-the-knee amputation and phantom limb pain would most likely benefit from contralateral stimulation. This technique effectively addresses neuropathic pain by altering pain perception through stimulation of the opposite limb, providing significant relief for phantom sensations.
A: A 36-year-old client with abdominal pain may not respond well to contralateral stimulation, as this method is primarily beneficial for neuropathic conditions rather than visceral pain sources like abdominal discomfort.
C: A 76-year-old client with terminal cancer typically experiences complex pain management challenges that may not be adequately addressed by contralateral stimulation, which is less effective for systemic or cancer-related pain.
D: An 84-year-old client with severe arthritis generally suffers from musculoskeletal pain, which contralateral stimulation may not significantly alleviate, as this intervention is more suited to neuropathic pain scenarios.
The nurse is interviewing a 25-year-old female client who recently experienced domestic violence. What is the rationale for excluding the family from the interview to ensure a safe and confidential environment? Select all that apply.
Rationale:
Excluding the family from the interview promotes client autonomy, maintains privacy and confidentiality, prevents potential intimidation or coercion, and minimizes the risk of retaliation, creating a safer environment for the client to express herself.
B: Maintain family dynamics and support. Including family members could compromise the client's ability to speak freely, undermining the support that should be based on trust and safety.
A nurse prepares a client for computed tomography (CT) scan with intravenous (IV) iodinated contrast. The nurse should take which action?
Rationale:
Ask the client if they are allergic to shellfish. This action is crucial as individuals allergic to shellfish may also react to iodinated contrast due to similar protein structures, potentially leading to severe allergic reactions during the CT scan.
B: Insert a 20-gauge peripheral vascular access device. While establishing IV access is important, identifying allergies takes precedence to prevent any adverse reactions during the procedure.
C: Obtain capillary blood glucose (CBG). Monitoring blood glucose levels is not relevant for a CT scan with contrast, as the primary concern is the potential for allergic reactions.
D: Instruct the client to decrease their fluids after the procedure. Encouraging hydration is essential post-procedure to help flush the contrast material from the body, not to limit fluid intake.
The nurse is caring for a client in pain. The nurse asks the client which level of pain he is in, and the client says it's 1 out of 10. The nurse notices that the client grimaces every time he moves. What is the nurse's most appropriate action?
Rationale:
C: Ask the client about his grimacing with every movement. The nurse should investigate the client's pain further since the reported level of pain does not align with observed behaviors, indicating a potential underreporting of discomfort or an underlying issue requiring attention.
A: Administer analgesics to the client. Providing medication without understanding the client's pain experience may overlook significant underlying issues that need to be addressed first.
B: Move on to other patients. Focusing on other clients neglects the immediate need to assess and address the client's pain, potentially leading to inadequate care.
D: Encourage the client to watch his favorite TV show. Suggesting distraction does not address the client’s evident pain or grimacing, which may require more direct interventions or assessments.
The nurse is caring for a client scheduled for electroconvulsive therapy (ECT). To prevent complications during and after the procedure, the nurse should assess the client's
Rationale:
The nurse should assess the client's dentition. Proper oral health is critical since ECT can induce muscle contractions, increasing the risk of dental injury during the procedure.
A: sensation in the lower extremities. This assessment is not directly related to the risks associated with ECT, which primarily involve potential oral and dental complications.
C: grip strength. While important for overall health, grip strength does not specifically pertain to the complications that may arise during or after ECT treatment.
D: peripheral vision. Although vision is important, peripheral vision does not directly relate to the immediate concerns of ECT, such as oral safety and the risk of dental injury.
The nurse is preparing a client scheduled for hip arthroplasty in two hours. The nurse has received a prescription for tranexamic acid. The nurse understands that this medication has had a therapeutic effect when the client has
Rationale:
The client has less postoperative blood loss. Tranexamic acid works by inhibiting fibrinolysis, thereby reducing bleeding during and after surgery, which is crucial for patients undergoing procedures like hip arthroplasty.
A: decreased postoperative pain. Tranexamic acid primarily addresses bleeding rather than pain relief, so it does not directly influence the client's pain levels post-surgery.
B: increased postoperative vital capacity. The medication does not impact respiratory function or vital capacity, which are influenced by lung mechanics and patient mobility rather than bleeding management.
D: no surgical site infection. Tranexamic acid has no antimicrobial properties, thus it does not prevent infections, which are dependent on surgical technique and postoperative care rather than blood loss.
A nurse is taking care of a client undergoing cerebral angiography. Which statement by the client would require immediate follow-up?
Rationale:
D: My throat is getting a bit itchy, and my eyes are getting watery. This statement indicates a potential allergic reaction to the contrast dye used in cerebral angiography, which necessitates immediate medical attention to prevent serious complications.
A: I feel like I'm going to vomit. While nausea can occur, it is a common side effect and typically does not require urgent intervention unless accompanied by other concerning symptoms.
B: I hope my results are okay. This expression reflects anxiety about the procedure's outcomes and does not indicate any immediate health concerns that necessitate follow-up.
C: It's getting a bit hot in here. Feeling warm may be a normal response to anxiety or the environment, and does not signify a critical or urgent medical issue requiring immediate action.
The nurse is assessing a client who just returned from surgery. The nurse checks preoperative vital signs at 0830 to compare them with the current vital signs at 1030 . What action should the nurse take?
Rationale:
Administer oxygen at 2 L/minute. The nurse prioritizes the client's immediate respiratory needs after surgery, particularly if there are indications of compromised oxygenation. Administering oxygen can stabilize vital signs effectively during recovery.
A: Assess the surgical wound. While monitoring the surgical site is vital, the immediate concern is ensuring adequate oxygenation post-anesthesia rather than evaluating the wound initially.
B: Collect blood cultures. This action is not immediately necessary after surgery unless there are signs of infection; the focus should be on monitoring vital signs and respiratory status.
D: Encourage by-mouth (PO) fluids. Administering oral fluids may be inappropriate immediately post-surgery due to potential nausea or risk of aspiration; oxygen delivery takes precedence to maintain adequate oxygen saturation.
The nurse is supervising a student assisting a client with their newly prescribed crutches. Which action by the student requires follow-up by the nurse? The student
Rationale:
The handgrips must not support the client's body weight at the axillae, as this can lead to nerve damage. Crutches should be used primarily for stability while bearing weight on the hands.
B: Demonstrates the proper crutch stance at 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot. This positioning is essential for maintaining balance and safety while using crutches.
C: Observes two to three finger widths between the crutch pad and the client's axilla. This distance ensures proper fitting and prevents injury to the axilla during crutch use.
D: Instructs the client to dry crutch tips with a paper towel if they become wet. Ensuring dry crutch tips is important, but drying them with a towel may not provide thorough safety.
The patient is experiencing post-operative tachycardia with low blood pressure. The nurse should be most concerned about which of the following surgical complications?
Rationale:
Post-operative tachycardia with low blood pressure indicates potential hemorrhage. This condition can lead to significant blood loss, compromising hemodynamic stability, and requires immediate intervention to prevent shock and further complications.
A: The development of an infection Infection typically presents later and is less likely to cause immediate hemodynamic changes compared to hemorrhage, making it a lesser concern in this scenario.
C: Wound dehiscence While wound dehiscence is a serious issue, it does not directly contribute to low blood pressure and tachycardia in the immediate post-operative context, thus less urgent.
D: Hematoma Hematomas can cause localized swelling and pain, but they usually do not result in systemic symptoms like tachycardia and hypotension, making them a less critical concern in this situation.
The nurse is observing a student nurse wash their hands with soap and water. Which observation requires follow-up? The student nurse
Rationale:
C: Wets their wrists and hands with fingers pointed downward.
This observation requires follow-up because proper handwashing technique dictates that fingers should be pointed downward to prevent water from running back down the arms, which can contaminate clean hands.
A: washes their hands using warm water.
Using warm water is preferred as it enhances the effectiveness of soap in removing dirt and pathogens, promoting better hygiene.
B: dries hands thoroughly from wrists to fingers with paper towel.
Thorough drying from wrists to fingers is essential for preventing the growth of bacteria, ensuring hands remain hygienic after washing.
D: pushes wristwatch and long uniform sleeves above wrists.
This action is commendable as it prevents contamination from clothing and accessories, ensuring a cleaner handwashing process and reducing the risk of infection.
The nurse is performing an initial home health visit on a client who had a stroke one week ago with left-sided hemiparesis. Select the findings in the admission note that require follow-up.
Rationale:
The client reported flat affect and withdrawal, indicating potential emotional distress or depression following the stroke. These psychological symptoms require further assessment and intervention to support the client's mental well-being during recovery.
B: The client reported full adherence to their prescribed medications. This statement reflects positive compliance, suggesting the client is managing their health effectively, thus not necessitating follow-up.
E: The client ambulated with the cane and held it in their right hand. This demonstrates functional mobility, indicating that the client is able to use assistive devices appropriately, requiring no further follow-up.
F: The client advanced the cane 12-14 inches (30-36 cm) with each step. This action shows proper technique in ambulation, which is important for safety, therefore not warranting any additional follow-up.
The nurse is teaching a group of students on incident reports. Which of the following situations would require an incident report? Select all that apply.
Rationale:
B: Complaining about poor care from a nurse, C: Leaving against medical advice (AMA), and E: Threatening a nurse with bodily harm are all situations that necessitate filing an incident report due to potential risks, legal implications, and the need for institutional awareness and response to ensure patient safety and quality care.
A: Requesting to view their medical record indicates a patient’s right to access information, not a safety concern or incident needing reporting.
D: Requesting an increase in pain medication reflects a patient’s desire for proper pain management, not an incident that compromises safety or requires documentation of an unusual event.
The nurse cares for a client scheduled for spinal surgery in one hour. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe
Rationale:
Enoxaparin is anticipated to be prescribed by the PHCP for the client scheduled for spinal surgery. This medication is commonly used for thromboprophylaxis, reducing the risk of deep vein thrombosis in surgical patients.
A: Gentamicin This antibiotic is typically utilized for treating infections, not for pre-operative care, making it unsuitable for a client preparing for spinal surgery.
C: Hydromorphone This opioid analgesic is primarily used for pain management rather than preventive measures prior to surgery, which is not the focus of pre-operative prescriptions.
D: Cyclobenzaprine As a muscle relaxant, it’s generally prescribed for muscle spasms, not relevant for a surgical context where thrombosis prevention is paramount.
The occupational health nurse is conducting an in-service on reducing back injuries in the workplace. It would be correct for the nurse to identify that the most common location of back injuries is in the
Rationale:
Back injuries most commonly occur in the lumbar spine.
The lumbar spine bears the most weight and is subject to significant strain during daily activities, making it a frequent site for injury among workers engaged in physically demanding tasks.
A: Cervical spine. While cervical injuries can happen, they are less prevalent than lumbar injuries, primarily because the cervical region is not typically subjected to heavy lifting.
C: Thoracic spine. The thoracic spine is more stable and less involved in movements associated with lifting, resulting in fewer injuries compared to the lumbar region.
D: Pelvis. Though pelvic injuries can occur, they are not as common as lumbar injuries, which directly result from improper lifting and heavy loads.
The nurse is planning care for a client diagnosed with Mycoplasma pneumonia. The nurse should plan to
Rationale:
Wear a surgical mask within 3 feet of the client. This precaution is critical as Mycoplasma pneumonia is transmitted through respiratory droplets, necessitating mask use to prevent spreading the infection during close contact.
A: place the client in a private room with negative airflow. Mycoplasma pneumonia is not airborne; therefore, negative airflow is unnecessary for managing this type of infection.
C: wear gloves when in contact with the client. While gloves are important for contact precautions, Mycoplasma pneumonia primarily spreads through droplets, making masks the priority.
D: provide disposable meal trays and utensils. There’s no evidence suggesting that Mycoplasma pneumonia requires disposable items; standard hygiene practices are sufficient for managing food-related interactions.
The nurse recognizes which of the following would contraindicate the use of electronic blood pressure monitoring?
Rationale:
Coarse tremors would contraindicate the use of electronic blood pressure monitoring. Tremors can cause erratic movements that lead to inaccurate readings, compromising the reliability of the monitoring equipment and the patient's care.
B: Intrajugular central vascular access device does not interfere with electronic monitoring, as it is unrelated to blood pressure measurement directly and does not affect the accuracy of the readings.
C: Wearing a wrist watch does not pose a barrier to electronic blood pressure monitoring, as it typically does not obstruct the sensor or interfere with the measurement process in any significant way.
D: Cardiac pacemaker does not contraindicate electronic blood pressure monitoring; these devices are designed to function independently and do not disrupt the electronic measurements of blood pressure.
The nurse is caring for a client three hours postoperative following a laparoscopic appendectomy. Which of the following client data indicates the client is ready for discharge home?
Rationale:
A: Positive gag reflex indicates the client is ready for discharge home as it reflects the return of normal gastrointestinal function post-surgery, essential for safe recovery, particularly after anesthesia.
B: Hypoactive bowel sounds suggest decreased gastrointestinal activity, which may indicate complications or a delayed recovery, thus making discharge premature and potentially unsafe for the client.
C: Blood pressure 90/60 mm Hg signifies hypotension, potentially indicating inadequate perfusion or complications, which necessitates further monitoring and management before considering discharge for the client.
E: Incisional pain '2' on a scale of 0 to 10 indicates manageable pain levels, but it does not alone confirm readiness for discharge without considering other critical recovery parameters.
The nurse assesses a client who requires bilateral wrist restraints for agitation and hostility toward staff. When performing follow-up assessments, what data is necessary for the nurse to obtain? Select all that apply.
Rationale:
B: Skin integrity, C: Behavioral status, and D: Vital signs are crucial for ongoing assessments to ensure the client's safety and monitor potential complications associated with restraint use. Evaluating these aspects helps determine the effectiveness of interventions and the need for continued restraint application.
A: Previous restraint use lacks immediate relevance for current assessments, focusing instead on the present state and current condition of the client.
E: Urinary continence does not directly relate to the immediate concerns of agitation and hostility, making it less pertinent in the context of assessing the need for restraints.
Which of the following children would the nurse identify as a priority for having the greatest risk for choking and suffocating?
Rationale:
A toddler playing with his 9-year-old brother's construction set. The construction set likely contains small parts that pose a choking hazard, making the toddler particularly vulnerable to choking or suffocation while playing.
B: A 5-year-old eating yogurt for a snack. Yogurt is generally safe and easy to swallow, posing minimal risk of choking compared to solid or small food items.
C: An infant asleep in her crib without a blanket. An infant without a blanket is at a lower risk for suffocation, as blankets can obstruct airflow, but absence reduces hazards.
D: A 3-year-old drinking a glass of juice. Juice is typically not a choking hazard, as it's liquid and easily swallowed, presenting less danger compared to solid items.
The nurse is recommending respite care to a client and their caregiver. The nurse understands that this care is designed to
Rationale:
Respite care offers short-term relief by providing caregivers who support the ill, disabled, or frail older adults time to relax. This care allows caregivers to recharge while ensuring the client receives appropriate assistance and supervision.
A: Improve the quality of life of clients and families who are experiencing problems related to life-threatening illnesses. This option focuses more broadly on quality of life rather than the specific short-term relief for caregivers.
B: Provide a variety of health and social services to specific patient populations. While health and social services are important, this option does not specifically address the needs of caregivers for temporary respite.
C: Have clients live with comfort, independence, and dignity while easing the pain of terminal illness. This emphasizes client comfort rather than the caregiver's need for temporary relief, which is the primary focus of respite care.
The nurse is caring for a postoperative client who is ordered to use an incentive spirometer. The nurse understands that this device will help prevent which complication?
Rationale:
C: The incentive spirometer helps prevent hypostatic pneumonia by promoting deep breathing and lung expansion, which enhances ventilation and oxygenation, reducing the risk of fluid accumulation in the lungs post-surgery.
A: venous thromboembolism Deep breathing exercises with an incentive spirometer do not directly address blood flow issues or clot formation associated with venous thromboembolism, which involves the circulatory system.
B: obstructive sleep apnea The incentive spirometer's purpose is not to manage sleep-related breathing disorders like obstructive sleep apnea, which is primarily related to airway obstruction rather than lung expansion.
D: aspiration pneumonia While aspiration pneumonia involves inhalation of foreign materials into the lungs, the incentive spirometer is not specifically designed to prevent this type of pneumonia, focusing instead on improving lung function.
The nurse is caring for a child immediately postoperative following a left ear myringotomy. The nurse should position the child
Rationale:
The child should be positioned right lateral recumbent. This position promotes drainage from the left ear after myringotomy, preventing fluid accumulation and facilitating optimal healing while minimizing discomfort.
A: left lateral recumbent This position would place the surgical site downward, potentially causing fluid to pool in the ear and increasing the risk of complications.
B: prone Positioning the child face down is not appropriate as it could hinder proper drainage and monitoring of the ear, compromising recovery.
D: modified trendelenburg This position elevates the legs and head, which does not specifically assist in drainage from the left ear and may not support post-operative care effectively.