The emergency department (ED) charge nurse is preparing for a surge of clients diagnosed with Ebola virus disease (EVD). The nurse should plan to take which action? Select all that apply.
Rationale:
Implement visitor restrictions for affected clients, log entry and exit of all healthcare workers who provide care, and have an observer for donning and doffing of personal protective equipment.
Implementing visitor restrictions minimizes the risk of transmission, logging healthcare worker movement ensures accountability, and having an observer during PPE procedures enhances safety and adherence to protocols in a high-risk environment like EVD management.
C: Ensure that bleach disinfectant wipes are available in each room. While disinfectants are essential, this action alone does not address the critical need for visitor management and PPE oversight.
D: Provide reusable personal protective equipment. Reusable PPE may not be advisable in Ebola cases as single-use equipment is often more effective in preventing contamination and ensuring proper disposal protocols.
The nurse is teaching a client about a vegetarian diet. Which of the following foods should the nurse recommend for this diet? Select all that apply.
Rationale:
Legumes, almond butter, and apricots are recommended for a vegetarian diet as they provide essential nutrients, proteins, and healthy fats while aligning with plant-based dietary principles. These foods support overall health and meet the nutritional needs of individuals avoiding animal products.
C: Grilled chicken Contains animal protein, making it unsuitable for a vegetarian diet focused on plant-based foods and alternatives.
E: Baked fish Fish is an animal product, which does not fit within the vegetarian dietary guidelines that exclude all forms of meat and seafood.
F: Seafood salad Similar to fish, seafood is not compatible with a vegetarian diet, as it consists of animal-derived ingredients contrary to vegetarian principles.
The nurse is teaching a continuing education course on communicable diseases. Which of the following statements should the nurse make about diphtheria? Select all that apply.
Rationale:
The organism that causes this condition is Corynebacterium diphtheriae, vaccination is available starting at two months of age, transmission of cutaneous diphtheria is via direct contact, and airborne precautions are required for pharyngeal diphtheria.
A: The organism that causes this condition is Corynebacterium diphtheriae. This statement accurately identifies the pathogen responsible for diphtheria, emphasizing its bacterial nature and significance in understanding the disease.
B: Vaccination is available starting at two months of age. This option correctly indicates the timing of vaccination, which is crucial in preventing the disease, but is not the only relevant statement.
C: Transmission of the cutaneous diphtheria is via direct contact with the infected person. While this describes cutaneous diphtheria correctly, it does not encompass the full scope of diphtheria transmission.
D: Airborne precautions are required for individuals with pharyngeal diphtheria. Although airborne precautions are necessary for pharyngeal cases, this choice alone fails to capture the broader aspects of diphtheria management.
E: Diphtheria is caused by a virus and is highly contagious. This statement misidentifies the causative agent, attributing the disease incorrectly to a virus rather than the bacterial pathogen, and oversimplifies its contagion risk.
The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
Rationale:
Frequent swallowing requires immediate follow-up. This may indicate bleeding or hemorrhage post-tonsillectomy, which can lead to serious complications. Monitoring this symptom is crucial for ensuring the child's safety and recovery.
A: Discomfort while speaking is a common postoperative symptom as the throat heals and does not typically signal an urgent issue.
C: Drowsiness can occur after anesthesia and is not uncommon post-surgery, provided the child is responsive and stable.
D: Pain with occasional coughing can be expected after surgery and usually does not indicate a critical concern unless accompanied by other alarming signs.
The nurse is caring for an older adult receiving prescribed antibiotics for an infection. The client reports frequent watery stools that are foul-smelling. To prevent the spread of any potential secondary infection, the nurse should
Rationale:
Place the client on contact (enteric) precautions. This measure is essential to minimize the risk of transmitting potential infectious agents from the client's frequent, foul-smelling, watery stools to other patients and healthcare staff.
B: Place a surgical mask on the client during transport. This action does not address the primary concern of preventing the spread of infection related to gastrointestinal symptoms.
C: Place face shields outside of the client's room. Utilizing face shields outside the room does not directly mitigate the risk of contamination from the client's enteric condition.
D: Keep the door to the client's room closed. While this may help limit airflow, it does not specifically prevent the spread of infections related to contact with contaminated surfaces.
The nurse is performing a health assessment on a client. While performing percussion, which percussion sound would require follow-up?
Rationale:
Hyperresonance over an adult's lung tissue would require follow-up. This sound indicates excessive air in the lungs, often associated with conditions like pneumothorax or emphysema, necessitating further evaluation and intervention.
A: Dull tone over the spleen indicates fluid or mass presence, which is generally expected; it does not typically warrant immediate concern unless accompanied by other symptoms.
C: Flat tone over bone is a normal finding, reflecting the density of bone structure, and does not suggest any pathological condition that would require follow-up.
D: Hyperresonance over a child's lung tissue can be normal, particularly in younger individuals due to their smaller thoracic cavity; it does not inherently indicate a problem needing immediate attention.
The nurse plans to use a mechanical lift to transfer a client from a stretcher to a wheelchair. Which appropriate action should the nurse take?
Rationale:
Instruct the client to fold their arms over their chest. This action promotes safety during the transfer by providing stability, preventing potential injury, and facilitating a smoother, more controlled movement from the stretcher to the wheelchair.
A: Keep the stretcher's side rails raised during the transfer. Raised side rails could restrict the client's movement and create unnecessary obstacles, leading to potential safety hazards during the transfer process.
C: Apply gloves and gown for this procedure. While infection control is important, personal protective equipment is not required for this type of transfer unless there's a risk of exposure to bodily fluids.
D: Unlock the wheels on the stretcher and wheelchair. Unlocking the wheels could lead to instability during the transfer, increasing the risk of accidents and compromising the safety of both the client and the caregiver.
The nurse is prioritizing caring for four assigned clients. Based on the pulse (P), respiratory rate (R), and blood pressure (BP) provided, which of the clients should the nurse follow up with first?
Rationale:
B: P: 90; R: 12; BP: 99/54 mmHg. This client exhibits bradycardia with a pulse rate of 90 and a low blood pressure of 99/54 mmHg, indicating potential cardiovascular instability that requires immediate attention.
A: P: 109; R: 26; BP: 110/70 mmHg. Elevated pulse and respiratory rates suggest heightened physiological stress, but the blood pressure remains stable, indicating less immediate concern compared to option B.
C: P: 100; R: 18; BP: 161/98 mmHg. Although this client has hypertension, the stable pulse and respiratory rates do not present an urgent threat compared to the concerning parameters of option B.
D: P: 88; R: 14; BP: 166/52 mmHg. Despite low pulse and respiratory rates, the significantly high blood pressure indicates a chronic issue rather than an immediate crisis, making it less urgent than option B.
The nurse is counseling a client diagnosed with irritable bowel syndrome (IBS). The nurse should advise the client to increase their
Rationale:
Increasing fiber intake is crucial for clients with irritable bowel syndrome (IBS) as it helps regulate bowel movements, reduces constipation, and may alleviate some symptoms associated with the condition.
A: Dairy intake. Many individuals with IBS are lactose intolerant, and increasing dairy consumption could exacerbate symptoms such as bloating and diarrhea, making it an unsuitable recommendation.
C: Fat intake. A high-fat diet can worsen IBS symptoms by slowing digestion and causing discomfort, which is not advisable for managing the condition effectively.
D: Calcium intake. While calcium is important, simply increasing calcium intake does not address the primary symptoms of IBS and may not contribute to symptom relief or improved bowel function.
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:
Using an incentive spirometer helps prevent hypostatic pneumonia. This device encourages deep breathing, promoting lung expansion and effective ventilation, which reduces the risk of fluid accumulation and infection in the lungs post-surgery.
A: venous thromboembolism Deep breathing exercises do not directly influence blood flow or clot formation, which are the primary concerns associated with venous thromboembolism after surgery.
B: obstructive sleep apnea Incentive spirometry primarily aids lung function and does not address the airway obstruction issues characteristic of obstructive sleep apnea, which involve different physiological mechanisms.
D: aspiration pneumonia While incentive spirometry supports lung health, aspiration pneumonia specifically arises from inhaling foreign materials, an issue not mitigated directly through the use of this device.
A nurse is conducting infection control assessments on the nursing unit. Which client is at the greatest risk for infection? A client
Rationale:
D: Receiving total parenteral nutrition (TPN) via a central line. This client is at significant risk for infection due to the invasive nature of the central line, which can introduce pathogens directly into the bloodstream, compromising their immune response and increasing susceptibility to infections.
A: Withdrawing from alcohol and is malnourished. While this client has health concerns, the primary risk for infection arises from invasive procedures rather than general malnutrition or withdrawal symptoms.
B: Receiving methylprednisolone for an asthma exacerbation. Although corticosteroids can suppress the immune system, this client's risk is lower compared to those with invasive lines, which pose direct infection threats.
C: Has an external urinary catheter device for urinary incontinence. External catheters can pose infection risks, but they do not present the same level of danger as central lines used for TPN administration.
The nurse cares for a client in the outpatient surgical center who is scheduled for a cholecystectomy
Item 1 of 1
Nurses' Note
0730 – The client arrives at the preoperative area with his family. He reports that he is anxious about the procedure. The pre-operative assessment was completed at this time. 20-gauge peripheral vascular access established in the right antecubital space. + blood return and flushes without resistance. The client reports no pain at the insertion site.
The nurse reviews the completed pre-operative assessment.Select the findings on the assessment that require follow-up
Rationale:
The surgeon has not obtained informed consent. Informed consent is a critical legal and ethical requirement before surgery, ensuring the client understands the procedure and potential risks involved, which was not completed.
A: ID verified and band applied. This finding indicates that identification protocols were properly followed, ensuring patient safety and identity verification before the procedure, which does not require follow-up.
C: Client took his prescribed phenytoin with a sip of water this morning. Taking phenytoin as prescribed is appropriate, but the timing may need clarification regarding medication instructions prior to surgery, thus not necessitating follow-up.
E: The client stated he was going to drive himself home after the procedure. Driving post-anesthesia is unsafe due to potential impairments from sedation, warranting attention, but it is not a pre-operative assessment finding.
You are educating a mother about the association between autism and the MMR vaccine. You know that the mother understands your instructions when she says:
Rationale:
My child should get the MMR immunization since there is no evidence that it causes autism. This statement reflects a comprehensive understanding of current scientific consensus, which demonstrates that extensive research has found no link between the MMR vaccine and autism development in children.
A: My child should not get the vaccine since it is known to cause autism. This belief is based on debunked studies and misinformation, which have been thoroughly discredited by reputable health organizations.
B: My child should get the individual immunizations for measles, mumps, and rubella since the individual vaccines do not cause autism. While individual vaccines may not cause autism, this choice overlooks the benefits of the combined MMR vaccine's efficacy and safety.
D: My child should not get the immunization because it contains mercury. Current formulations of the MMR vaccine do not contain mercury, making this concern outdated and irrelevant to vaccine safety discussions.
The nurse observes a patient walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Which of the following should the nurse assess in the patient?
Rationale:
The patient should be assessed for pain. The stooped gait, facial grimacing, and gasping sounds suggest the individual may be experiencing significant discomfort, necessitating an evaluation of pain levels to provide appropriate care.
B: Anxiety The observed physical signs do not primarily indicate anxiety, as they are more closely aligned with physical pain or discomfort rather than emotional distress or nervousness.
C: Depression While depression can manifest in various ways, the patient's physical symptoms specifically point towards a potential acute issue like pain rather than chronic emotional states associated with depression.
D: Fluid volume deficit The symptoms displayed are not typical indicators of fluid volume deficit; instead, they strongly suggest an immediate need to evaluate pain rather than hydration status.
The nurse is teaching a group of students about medications and fall prevention. The nurse would be correct in identifying which of the following medications can increase the risk for falls? Select all that apply.
Rationale:
Alprazolam, bumetanide, and verapamil can increase the risk for falls due to their potential side effects, such as sedation, dizziness, and orthostatic hypotension, which can impair balance and coordination in patients.
A: naproxen Non-steroidal anti-inflammatory drugs like naproxen generally do not contribute to fall risk and are primarily used for pain relief without significant impact on balance or stability.
E: allopurinol This medication is used to manage gout and does not affect the central nervous system or balance, hence it does not heighten the risk of falls in patients.
F: thiamine Thiamine, a vitamin supplement, primarily supports metabolism and neurological function, without any sedative properties or effects that would increase the likelihood of falls.
The nurse is ambulating a client who is wearing a gait belt. The client begins to fall. The nurse should take which appropriate action to minimize injury?
Rationale:
Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor. This method provides maximum control and support, ensuring the client's safety during the fall while minimizing potential injury by allowing a gradual descent.
B: Let go of the gait belt, grab the client under each arm, and gently lower the client to the floor. Releasing the gait belt compromises control, increasing the risk of the client falling awkwardly and sustaining injuries.
C: Grasp the gait belt, and instruct the client to fall gently down to the floor in a side-lying position. This approach places the burden on the client to manage their fall, which can lead to unpredictable outcomes and potential harm.
D: Hold the gait belt, and lower the client to the floor by using a narrow base of support. Utilizing a narrow base of support can destabilize both the nurse and the client, increasing the likelihood of injury during the fall.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 3 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
The nurse updates the nursing note with an environmental assessment for a 67-year-old female client with progressive multiple sclerosis. The nurse should first address the client's
Rationale:
D: Environmental hazards.
The nurse should first address environmental hazards, as clients with progressive multiple sclerosis may experience mobility challenges and increased risk of falls. Ensuring a safe living space is crucial for preventing injuries and promoting independence in daily activities.
A: Fatigue. Fatigue management is important, but addressing safety concerns takes precedence to prevent accidents in the client's living environment.
B: Sensation in the extremities. While sensation changes are significant, they do not pose immediate risks like environmental hazards, which can lead to severe consequences if not managed.
C: Nutritional intake. Although proper nutrition supports overall health, ensuring the client’s safety from environmental risks is vital for enhancing their quality of life and preventing potential injury.
The nurse is discussing the risk of delayed wound healing following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication?
Rationale:
B: Cushing's syndrome. This condition is characterized by excessive cortisol production, which can impair wound healing by inhibiting inflammatory responses and collagen synthesis, ultimately leading to delayed recovery after surgery.
A: Diabetes insipidus. This condition primarily affects water balance and does not directly influence the body's ability to heal wounds or manage surgical recovery effectively.
C: Hemophilia. While hemophilia affects blood clotting, it does not inherently delay wound healing; it mainly causes issues with bleeding rather than the healing process itself.
D: Inflammatory bowel disease. Although this condition can cause systemic inflammation, it does not specifically lead to delayed wound healing following surgery, unlike Cushing's syndrome, which directly impairs healing mechanisms.
The nurse is preparing for a client to undergo a closed reduction of the shoulder with moderate (procedural) sedation. The nurse plans on obtaining which clinical data during the procedure?
Rationale:
Blood pressure, end-tidal carbon dioxide level, respiratory rate, and oxygen saturation are all critical parameters to monitor during moderate sedation. These values help ensure the client maintains adequate hemodynamic stability and respiratory function throughout the closed reduction procedure.
A: Blood pressure Continuous monitoring is essential for assessing cardiovascular stability and detecting any potential complications during sedation.
B: End-tidal carbon dioxide [ETCO2] level While ETCO2 is important in sedation, it specifically measures ventilation rather than systemic stability.
C: Respiratory rate Monitoring respiratory rate is vital, but it is not as comprehensive as blood pressure in assessing overall patient stability.
D: Blood glucose Although important in some contexts, blood glucose does not directly relate to the immediate safety concerns during procedural sedation.
The nurse is having difficulty locating a vein, to start intravenous therapy, on a client who is dark-skinned. Which of these devices or procedures may be of benefit to you at this time?
Rationale:
A transillumination device may be beneficial for locating veins in dark-skinned clients. This device uses light to illuminate underlying veins, making them more visible and facilitating easier access for intravenous therapy.
A: A doppler detects blood flow but does not visually illuminate veins, limiting its effectiveness in locating them in darker skin tones.
B: A surgical vein cut down involves invasive procedures that aren't necessary if non-invasive methods can successfully identify veins, making it a less favorable option initially.
D: A sonography provides an ultrasound image of veins but may not be readily available or suitable for immediate, quick access compared to transillumination techniques.
Following scheduled radioactive iodine therapy in a nuclear medicine department, a nurse is speaking with a client following the client's ingestion of radioactive iodine regarding strategies to avoid radiating the client's family members. The nurse recognizes the need for additional client teaching when the client states:
Rationale:
C: I'll travel for a couple of weeks to prevent my family from receiving radiation from me. This statement indicates a lack of understanding regarding the duration and nature of radiation exposure risks after therapy.
A: I understand the need to avoid sharing food or utensils with others. This demonstrates adequate comprehension of basic safety measures to protect family members from radiation exposure.
B: My children will miss my hugs and kisses for the next week. This shows concern for emotional connection but overlooks the importance of physical distance to minimize radiation exposure risks.
D: I understand the need to flush the toilet with the lid closed two to three times after each use. This indicates awareness of hygiene practices but doesn't encompass all necessary precautions for family safety.
The nurse is teaching a client about ambulating with a cane. It would indicate effective teaching if the nurse observes the client
Rationale:
D: Advances the cane 12-16 inches with each step. This demonstrates effective teaching, as it promotes proper gait mechanics, ensuring the client maintains balance, support, and a safe ambulation technique while using the cane.
A: Position the cane on their weaker side. This positioning would hinder stability, as the cane should support the stronger side to enhance balance during ambulation.
B: Advances their weaker leg first, then the cane. Correct ambulation requires the cane to be advanced first, followed by the weaker leg, ensuring maximum stability and support.
C: Measures the height of the cane from their wrist crease. While proper cane height is important, this action alone does not demonstrate effective ambulation technique, which involves movement patterns.
The nurse is performing a home safety assessment for an older adult. What environmental factors should be considered when assessing the client for risk for falls?
Rationale:
Vision loss and adequate lighting are critical environmental factors in assessing fall risk for older adults. Poor visibility can lead to missteps, while diminished sight increases vulnerability when navigating spaces, making proper illumination essential for safety.
A: Cognitive impairment This factor relates to mental processing but does not directly pertain to environmental safety elements, which are more focused on physical conditions affecting fall risks.
C: Hearing loss While hearing loss may affect awareness of surroundings, it does not involve immediate environmental hazards that can directly lead to falls, unlike vision and lighting conditions.
D: Adequate lighting Adequate lighting is vital for preventing falls, as it ensures that older adults can clearly see obstacles and navigate safely within their environment, thereby reducing risk.
The nurse is caring for a client immediately following scleral buckling surgery for a retinal detachment of the right eye. Which of the following actions would be appropriate for the nurse to take?
Rationale:
The client should be instructed to avoid bending down. This action helps prevent increased intraocular pressure, which could jeopardize the surgical outcome and the healing process following scleral buckling surgery.
A: Place the client in a prone position. This position can exert unnecessary pressure on the eye, which is counterproductive for recovery after retinal detachment surgery.
C: Instruct the client to perform deep breathing and coughing exercises. Deep breathing and coughing can increase intraocular pressure, potentially harming the surgical site and delaying healing.
E: Orientate the client to the environment. Proper orientation aids in the client’s comfort and safety, ensuring they are aware of their surroundings, especially following surgery.
F: Obtain a prescription for a stool softener. While managing bowel health is important, it is not an immediate priority in the context of recovery from eye surgery.
The nurse is teaching a group of unlicensed assistive personnel (UAPs) concepts of client identification. Which situation would require two client identifiers? Select all that apply.
Rationale:
Client identifiers are required when replacing a suction canister and obtaining vital signs to ensure that the correct procedures are performed on the correct patient, thereby enhancing safety and accuracy.
C: Replacing a suction canister. This procedure involves critical equipment that directly affects patient care, necessitating verification of the patient's identity for safety.
D: Obtaining vital signs. This process requires accurate identification to ensure that the right patient's health data is recorded and monitored effectively.
A: Providing a meal tray. This task typically does not involve direct clinical assessment, making it less critical for two identifiers compared to more invasive procedures.
B: Changing bed linens. While important, this task does not directly impact patient treatment or safety, thus not requiring strict identification measures.
E: Providing range of motion exercises. This activity is usually non-invasive and can be performed with less stringent identification protocols, focusing more on the care routine than critical identification.
The nurse is caring for a client with a tracheostomy who requires suctioning. Which of the following actions by the nurse would indicate correct technique?
Rationale:
Withdrawing the suction catheter 1 to 2 cm before applying suction indicates correct technique. This action prevents trauma to the tracheal mucosa and ensures effective clearance of secretions without causing unnecessary irritation or injury to the airway.
A: Using a size 16 Fr catheter to suction the client. This size may be too large, potentially causing airway obstruction or injury, depending on the client's tracheostomy size.
C: Using 160 mm Hg of pressure when suctioning the client. Suction pressure must be tailored to the patient’s needs, and excessive pressure can lead to complications like hypoxia or mucosal damage.
D: Applying suction to the catheter for 25 seconds during withdrawal. Continuous suctioning for this duration can result in tissue trauma and decreased oxygenation, which is not advisable in tracheostomy care.
The nurse is caring for a client admitted with severe pre-eclampsia. It would be essential for the nurse to have which of the following items at the bedside?
Rationale:
Suction equipment is essential at the bedside for a client with severe pre-eclampsia, as it facilitates immediate intervention in case of respiratory distress or airway obstruction, ensuring patient safety during potential complications.
A: One liter of 0.9% saline doesn't address immediate critical needs related to airway management, which is vital during severe pre-eclampsia due to possible rapid deterioration of the client's condition.
B: Sterile gloves are standard nursing supplies but do not directly relate to the urgent requirements for managing severe pre-eclampsia complications, particularly regarding airway protection and respiratory support.
C: Portable ultrasound is beneficial for monitoring fetal status but does not provide immediate assistance in emergencies, such as airway management, which is crucial for the client’s safety during severe pre-eclampsia.
The nurse is performing health screenings on a group of refugees. The nurse plans on performing which screening for this population group? Select all that apply.
Rationale:
C, D, E. Health screenings for refugees should include pulmonary tuberculosis, intestinal parasites, and viral hepatitis due to their increased vulnerability to infectious diseases and the higher risk associated with their living conditions.
A: Hypothyroidism. This condition is less prevalent in refugee populations compared to infectious diseases, which are more critical to address during health screenings.
B: Attention deficit hyperactivity disorder (ADHD). ADHD is a developmental condition that is less relevant for immediate health screenings compared to the urgent health risks faced by refugees.
Item 1 of 1
• Nurses' Notes
0920: Client presents for a follow-up visit. Client reports increased difficulty with activities of daily living because of dyspnea. Reports pain and swelling in both lower extremities that increases with movement. "Washing my hair now takes me an hour instead of fifteen minutes." Transverse surgical incision was pink, approximated, and crusted—9 inches in length. Two Jackson-Pratt drains contained a total of 15 mL of serumlike drainage. Incisional pain reported at a '4' on the Numerical Rating Scale. Endorses increased incisional pain while coughing. The client reports full adherence to postoperative enoxaparin self-injections. She reports ejecting the air bubble prior to injection. Reports relief with prescribed oxycodone-acetaminophen but experiences generalized itching and drowsiness after.
• Medical History
• gastric bypass surgery performed two years ago
• dyslipidemia
• diabetes mellitus (type two)
• Vital Signs
• T 99.0°F (37.2°C); HR 90 beats/min; RR 18 breaths/min; BP 119/67 mm Hg; Pulse oximetry 96% on room air.
The nurse in the medical office is caring for a 41-year-old client who is 2-week postoperative abdominoplasty. Which of the following assessment findings require immediate follow-up? Select all that apply.
Rationale:
Increased difficulty with activities of daily living, pain in lower extremities, and issues with enoxaparin self-injections necessitate immediate follow-up due to potential complications post-abdominoplasty.
B: Tolerance with activities of daily living indicates significant impairment and possible complications like decreased mobility or exacerbated pain, warranting urgent assessment to prevent further health deterioration.
C: Pain in lower extremities could suggest thromboembolic events or other serious conditions post-surgery, requiring prompt investigation to ensure patient safety and appropriate intervention.
D: Enoxaparin self-injections are critical for preventing deep vein thrombosis; any issues here could compromise the client's recovery and increase the risk of serious complications.
E: Pulse, respirations, and blood pressure are stable, showing no immediate concern; therefore, they do not require follow-up at this time since they indicate the client is currently stable.
The nurse is caring for assigned clients. Which essential infection control measure should the nurse take?
Rationale:
Perform hand hygiene before, after, and between providing direct client care. This measure is fundamental in preventing the transmission of infections, ensuring that pathogens are eliminated effectively, and maintaining a safe healthcare environment for both clients and healthcare providers.
B: Wear gloves while providing client care. While gloves are important, they do not substitute for hand hygiene and may lead to complacency if not used in conjunction with proper handwashing practices.
C: Cleanse equipment such as thermometers or stethoscopes between client care. Equipment hygiene is necessary but secondary to the primary action of handwashing, which directly affects personal and client safety.
D: Maintain a distance of 3 feet away from clients who are coughing. Physical distance can reduce exposure but is insufficient on its own; comprehensive infection control hinges on rigorous hand hygiene practices.
The nurse is supervising a newly hired nurse preparing a client for a computed tomography (CT) scan of the brain with intravenous (IV) contrast. Which action by the newly hired nurse requires follow-up?
Rationale:
D: Canceling the CT scan if the client reports a shellfish allergy. The presence of a shellfish allergy does not automatically necessitate cancelation, as many CT contrast agents do not contain shellfish derivatives. Alternative contrast options may be available, and further assessment is warranted before making such a decision.
A: Encouraging fluids when the client returns from the scan promotes hydration, aiding in the elimination of contrast material from the body. This practice is standard and beneficial post-procedure.
B: Confirming that the consent form is signed is critical for ensuring the client understands the procedure and its risks. This action is a fundamental responsibility of the nursing role.
C: Raising the side rails of the client's stretcher during transport enhances patient safety by preventing accidental falls. This precaution is essential during any movement of clients.
The nurse is applying a prescribed cold compress to the client's sprained ankle and recognizes that it should be applied for a maximum of
Rationale:
Applying a cold compress to the client's sprained ankle should be done for a maximum of 20 minutes. This duration helps reduce swelling and inflammation while preventing skin damage from prolonged exposure to cold.
B: 10 minutes. This time frame is insufficient for achieving optimal therapeutic effects, as longer application is often necessary to effectively manage swelling and discomfort.
C: 30 minutes. Exceeding this time can lead to adverse effects such as frostbite or skin irritation, which counteracts the intended benefits of the cold treatment.
D: 15 minutes. While close to the correct duration, this period may not provide enough time for the full anti-inflammatory effects needed for recovery.
The nurse is caring for a post-operative client at risk for a pressure ulcer. Which intervention should the nurse include in the plan of care?
Rationale:
Encouraging the consumption of high-protein foods is essential for promoting tissue repair and maintaining skin integrity in post-operative clients at risk for pressure ulcers. Adequate protein intake supports healing and reduces ulcer development likelihood.
A: Apply sequential compression devices. These devices are primarily used to enhance venous circulation and prevent deep vein thrombosis rather than directly addressing pressure ulcer prevention.
B: Apply an extra sheet to the bed. Simply adding a sheet does not effectively mitigate pressure on the skin or provide necessary support for preventing ulcers.
C: Position the client on a donut pillow. While this may relieve pressure in specific areas, it can cause increased pressure on other parts of the body, potentially exacerbating ulcer risk.
The nurse is caring for a client who has nausea related to prescribed chemotherapy treatments. The nurse should recommend that the client. Select all that apply.
Rationale:
A: Consume foods and liquids at room temperature. This option is beneficial as cooler foods and liquids can be easier to tolerate for clients experiencing nausea, reducing the likelihood of exacerbating symptoms.
C: Consume foods without aromas. Strong odors can trigger nausea, making bland, odorless foods a preferable choice for clients undergoing chemotherapy, enhancing their ability to eat.
D: Eat smaller portion sizes throughout the day. Smaller, more frequent meals can help manage nausea more effectively, preventing overwhelming feelings that larger meals may provoke.
B: Drink a large amount of fluid with meals. Consuming excessive fluids during meals can lead to a fuller stomach, potentially worsening feelings of nausea for clients undergoing chemotherapy treatment.
E: Delay taking the prescribed antiemetic until the nausea is severe. Waiting to take antiemetics until nausea becomes severe can result in more intense discomfort, making it harder to manage symptoms effectively.
The nurse is caring for a client two days post-operative following gastroduodenostomy. After reviewing the clinical data, the nurse should take which action?
Rationale:
Notify the physician for concerns of hypovolemic shock.
This action is crucial as post-operative patients are at high risk for complications, including hypovolemic shock. Early identification and intervention can prevent further deterioration and promote recovery, making it essential to communicate any alarming signs to the physician promptly.
A: Obtain a prescription for an antihypertensive. This action is premature without first assessing the patient's vital signs and overall stability, which could indicate the need for medication.
B: Determine if the client's pain is being controlled. While pain management is important, addressing potential life-threatening conditions like hypovolemic shock takes precedence over assessing pain levels at this stage.
C: Assess the client's surgical wound for signs of infection. Although monitoring the surgical site is necessary, immediate concerns regarding hemodynamic stability and potential shock should be prioritized over wound assessment.
The nurse is preparing to administer an enema to a client. Prior to administering this medication, the nurse should position this client
Rationale:
The client should be positioned in the left lateral position. This position promotes easier access to the rectum and allows for optimal administration of the enema while facilitating fluid retention.
A: Trendelenburg's position. This position is primarily used for increasing venous return and is not suitable for enema administration, which requires direct access to the rectum.
B: Semi-Fowler's position. This position is not ideal for enema administration, as it may hinder the necessary gravitational flow and retention of the enema solution.
D: Right lateral with the head of the bed lowered. This position does not provide the most effective alignment for administering an enema, which is best achieved in the left lateral position.
A school nurse is discussing poison prevention and management with a group of parents. Which statement by parents would indicate a need for additional teaching?
Rationale:
Vomiting should not be induced if gasoline is ingested, as it can cause further harm and lead to aspiration. Immediate medical attention is essential in such cases for proper treatment.
A: Containers of poisonous liquids need to be properly labeled. Proper labeling is crucial for safety, as it helps caregivers identify hazards and prevents accidental ingestion by children.
C: I may be able to give my child milk or water to dilute a corrosive poison while I rush them to the hospital. Diluting corrosive poisons can worsen the situation; immediate professional help is required instead of attempting home remedies.
D: All poisonous materials should be securely stored away from children. Secure storage is vital for preventing accidental exposure, ensuring that dangerous substances are inaccessible to curious children at all times.
The nurse is caring for a child admitted with varicella (chickenpox). Which of the following actions should the nurse take?
Rationale:
Wear a protective gown when transporting the client to other departments. This action is vital to prevent the spread of varicella, as the virus is highly contagious and can be transmitted through direct contact and airborne droplets.
A: Have a designated blood pressure cuff in the client's room. While important for infection control, it does not specifically address preventing varicella transmission during patient transport.
C: Clean commonly touched surfaces with warm, soapy water. This action aids in general hygiene but does not sufficiently protect against airborne or contact transmission of varicella in high-risk situations.
D: Remove all gowns and gloves after exiting the client's room. This procedure does not ensure continued protection against varicella, as proper gowning and gloving protocols are essential for maintaining infection control.
The nurse cares for a client with a double-lumen peripherally inserted central catheter (PICC). Which of the following actions would be appropriate for the nurse to take?
Rationale:
D: Aspirate each lumen for blood return and then flush. This action ensures patency of the double-lumen PICC and helps to prevent complications such as occlusion or thrombosis, maintaining effective venous access.
A: Assign the client to a private room. While isolation may be necessary for certain infections, it is not a routine requirement for clients with a PICC line.
B: Change the dressing daily using sterile technique. Dressings should typically be changed every 7 days or when soiled, not daily, to reduce the risk of infection and skin irritation.
C: Flush heparin prior to discontinuation. Heparin flushes are generally used for maintaining catheter patency, not required before removing the catheter, where saline flushes are more appropriate.
The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
Rationale:
Frequent swallowing indicates potential bleeding or hemorrhage, which is a critical concern following a tonsillectomy. This behavior could suggest that the child is attempting to manage blood accumulation in the throat, necessitating urgent assessment by the nurse to ensure patient safety and prevent complications.
A: Discomfort while speaking This can be a normal postoperative experience due to swelling and irritation, not necessarily indicating an urgent issue requiring immediate medical intervention.
C: Drowsiness Post-operative drowsiness may arise from anesthesia effects or pain management medications. It typically does not signal a critical concern unless accompanied by other alarming signs.
D: Pain with occasional coughing Mild pain and a rare cough are expected after surgery, often attributed to throat irritation. These symptoms do not typically warrant urgent follow-up unless they escalate.
The nurse is preparing to prime a new line of IV tubing. The nurse understands that priming intravenous tubing is crucial because it prevents which treatment complication?
Rationale:
Priming intravenous tubing is crucial to prevent air embolism. By removing air from the tubing, the risk of introducing air bubbles into the bloodstream during infusion is minimized, safeguarding the patient’s health.
A: Medication toxicity Excess medication dosage is related to improper administration, not directly linked to air in IV lines. Priming primarily addresses air presence rather than drug quantities.
B: Infiltration Infiltration occurs when IV fluid leaks into surrounding tissue, primarily due to catheter placement issues rather than air in the tubing. Priming does not target this concern.
D: Extravasation Extravasation results from vesicant medications causing tissue damage outside the vein, not from air in the IV line. Priming does not mitigate this specific risk.
The nurse is reviewing medical-surgical concepts with a group of nursing students. When discussing pain, it is appropriate for the nurse to categorize pain that occurs with short duration as
Rationale:
Acute pain. This type of pain is characterized by its short duration and typically arises from a specific injury or condition, signaling that something is wrong in the body.
A: Chronic pain. This pain persists over a longer period, often lasting for months or years, and is not classified as short duration like acute pain.
C: Referred pain. This type occurs in one part of the body while originating from another area, and does not relate to the short duration aspect of pain.
D: Neuropathic pain. This pain arises from nerve damage or dysfunction and can be chronic in nature, differing from the brief onset associated with acute pain.
A health care provider (HCP) orders the immediate use of a piece of electrical care equipment for a client. When the nurse goes to use the piece of equipment, the nurse immediately suspects it may be faulty. The nurse should take which initial action?
Rationale:
Immediately remove the piece of electrical care equipment from service.
Taking this action prevents potential harm to the client and others, ensuring safety is prioritized. The nurse is responsible for safeguarding against equipment hazards, making immediate removal essential for patient protection.
A: Try the piece of electrical care equipment and see if it becomes hazardous. This approach poses a significant risk to patient safety and could lead to serious injury or harm.
B: Call the health care provider and report your suspicion. While communication is important, reporting the suspicion does not address the immediate risk posed by potentially faulty equipment.
C: Ask the client if they want you to try the piece of electrical care equipment. This option places the client's safety at risk, as they should not be involved in decisions regarding potentially hazardous equipment use.
The nurse is preparing to admit a client following lumbar spinal fusion surgery. The nurse should instruct the unlicensed assistive personnel (UAP) to have which equipment at the bedside?
Rationale:
The overhead trapeze should be at the bedside.
The overhead trapeze facilitates patient mobility and support after lumbar spinal fusion surgery, allowing the client to reposition and assist with transfers, which is crucial for recovery.
B: Abduction pillow This equipment is primarily used in hip surgeries to maintain proper leg positioning and does not apply to lumbar spinal fusion recovery needs.
C: Transfer board While helpful for transferring patients, it does not provide the necessary support for upper body movement and self-assistance post-surgery.
D: Continuous passive motion (CPM) This device is generally utilized for knee rehabilitation, not indicated for lumbar spinal fusion recovery, where mobility support is a priority instead.
The nurse is preparing to remove a peripheral vascular access device. Which personal protective equipment (PPE) is necessary for this procedure?
Rationale:
Clean gloves are necessary for the procedure of removing a peripheral vascular access device to maintain hygiene and protect both the patient and the healthcare provider from potential contaminants.
A: Fluid resistant gown A fluid resistant gown is not needed for the removal of a peripheral vascular access device, as the procedure does not typically involve exposure to large amounts of bodily fluids.
C: Surgical mask A surgical mask is unnecessary for this procedure, as the risk of aerosol transmission or respiratory droplet exposure is minimal during the removal of the device.
D: Sterile gloves Sterile gloves are not required when removing a peripheral vascular access device, as clean gloves suffice to prevent infection without the need for a sterile environment.
The occupational health nurse is conducting an in-service on reducing back injuries. Which of the following statements, if made by a participant, would indicate a correct understanding of the conference?
Rationale:
C: I shouldn't twist while lifting an object.
This statement reflects an understanding of proper lifting techniques, emphasizing that twisting can increase the risk of back injury. Maintaining a stable posture while lifting helps protect the spine and reduces strain.
A: I should keep my legs straight while lifting.
Keeping legs straight while lifting does not distribute weight effectively, increasing the likelihood of injury. Proper lifting requires bending the knees and using leg strength instead.
B: Heavy objects should be held away from my body.
Holding heavy objects away from the body places additional strain on the back, leading to potential injury. Proper lifting involves keeping items close to the torso for better support.
D: I should keep a narrow base of support.
A narrow base of support can lead to instability during lifting. A wider stance enhances balance and reduces the risk of falling or straining the back while lifting.
The nurse observes a newly hired nurse apply bilateral soft-wrist restraints to a client. Which action by the newly hired nurse requires follow-up?
Rationale:
The newly hired nurse's action of repositioning the client from semi-Fowler's to prone requires follow-up. This position change can compromise the client's safety and comfort, particularly when restraints are applied.
A: Secures the restraint to the frame of the bed. Properly securing restraints to the bed frame is standard practice, ensuring safety and stability for the client in a restrained position.
C: Provides easy access to the quick release buckle. Ensuring easy access to the quick release buckle is essential for prompt intervention if the client experiences distress or an emergency arises.
D: Assesses the radial pulse every two hours. Regularly assessing the radial pulse every two hours is a necessary part of monitoring the client's circulation and overall well-being while restraints are in use.
The nurse teaches a client scheduled for an upcoming total hip arthroplasty. Which of the following statements by the client would require follow-up?
Rationale:
Clients are typically advised to avoid oral intake, including medications, prior to surgery. Therefore, the statement about taking an anticoagulant with water before surgery raises concerns about adherence to preoperative protocols.
A: I will need to bathe with chlorhexidine gluconate solution (CHG) the night before surgery to prevent an infection. This aligns with standard preoperative protocols aimed at minimizing infection risk.
B: I will need to take deep breaths and cough hourly. This statement is consistent with postoperative care to enhance lung function and prevent complications like pneumonia.
C: I will have to attend physical therapy sessions following my surgery. This reflects the importance of rehabilitation in recovery after total hip arthroplasty, promoting mobility and strength.
The nurse is caring for a client who reports abdominal pain. When performing an abdominal assessment, the nurse should
Rationale:
Auscultate for bowel sounds after inspecting the abdomen. This sequence is critical as it allows the nurse to observe the abdomen's appearance before applying pressure, which may alter bowel sounds or cause discomfort.
B: Palpate the area where the client identifies pain prior to palpating other areas. This approach could exacerbate discomfort and mislead the assessment, as it should follow auscultation.
C: Palpate to detect fluid, air, and fluid-filled or solid masses. Palpation serves a different purpose in the assessment process and should not precede auscultation to avoid misinterpretation.
D: Percuss for masses, tenderness, organ enlargement, and ascites. Percussion is a secondary technique and should only follow the initial steps of inspection and auscultation for a comprehensive assessment.
The perioperative nurse is documenting a client's current health status. It would be correct for the nurse to document the client's current position as: See the image in the exhibit.
Rationale:
The client’s current position is the Trendelenburg position. This position involves the patient lying on their back with the legs elevated higher than the head, which is crucial for certain medical procedures.
A: Prone The prone position involves the patient lying face down, which does not align with the description of the Trendelenburg position.
B: Supine The supine position refers to lying flat on the back, which differs from the elevation required in the Trendelenburg position.
D: The Sims’ position The Sims’ position involves lying on the side with one leg bent, which does not match the characteristics of the Trendelenburg position.