Nokea
To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? Select all.
- A. Hold the cane on the right side
- B. Keep 2 points of support on the floor
- C. Place the cane 15 inches in front of the feet before advancing
- D. After advancing the cane, move the weaker leg forward
- E. Advance the stronger leg so that it aligns evenly with the cane
Correct Answer: A, B, D
Rationale: Correct Answer: A, B, D
Rationale:
A: Holding the cane on the right side provides support for the weaker left lower extremity, aiding balance.
B: Keeping 2 points of support on the floor enhances stability and reduces the risk of falls.
D: Moving the weaker leg forward after advancing the cane promotes weight-bearing on the stronger leg first, reducing strain on the injured limb.
Summary:
C: Placing the cane 15 inches in front of the feet before advancing is too far and may lead to overreaching.
E: Advancing the stronger leg to align with the cane may shift the body weight incorrectly, increasing the risk of injury.
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A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all.
- A. Place the client in a room that has negative air pressure of at least 6 exchanges/hr
- B. Wear a mask when providing care within 3 ft of the client
- C. Place a surgical mask on the client if transportation to another dept is unavoidable
- D. Use sterile gloves when handling soiled linens
- E. Wear a gown when performing care that may result in contamination from secretions
Correct Answer: B, C, E
Rationale: The correct answers are B, C, and E.
B: Wearing a mask within 3 ft of the client helps prevent the transmission of pertussis through respiratory droplets.
C: Placing a surgical mask on the client during transportation reduces the spread of the infection to others.
E: Wearing a gown when handling secretions helps prevent contamination and spread of the infection.
Incorrect choices:
A: Negative air pressure is not necessary for the care of a pertussis patient.
D: Sterile gloves are not required for handling soiled linens in pertussis cases.
A nurse is assessing a client who is 5 days postop following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all.
- A. Increase in incisional pain
- B. Fever & chills
- C. Reddened wound edges
- D. Increase in serosanguineous drainage
- E. Decrease in thirst
Correct Answer: A, B, C
Rationale: The correct assessment findings the nurse should expect in a client suspected of having an incisional wound infection include: A) Increase in incisional pain: Infection can cause localized pain. B) Fever & chills: Systemic signs of infection. C) Reddened wound edges: Classic sign of wound infection. Incorrect choices: D) Increase in serosanguineous drainage: This is more indicative of normal wound healing. E) Decrease in thirst: Unrelated to wound infection. Overall, pain, fever, and redness are key signs of infection that the nurse should look out for.
An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she administers a PRN sedative med that the client has not requested along w/his usual meds. Which of the following tort has the nurse committed?
- A. Assault
- B. False imprisonment
- C. Negligence
- D. Breach of confidentiality
Correct Answer: B
Rationale: The correct answer is B: False imprisonment. False imprisonment occurs when a person is unlawfully restrained against their will. In this scenario, the nurse administering a sedative without the client's consent is considered an act of restraint, which restricts the client's freedom to leave. This action constitutes false imprisonment as the client is being detained without proper legal authority.
A: Assault involves the threat of harm or unwanted physical contact, which is not present in this situation.
C: Negligence refers to a failure to provide proper care or fulfill duties, which is not the case here.
D: Breach of confidentiality involves disclosing private information without consent, which is not relevant in this scenario.
In summary, the nurse committed false imprisonment by restricting the client's freedom of movement without legal justification.
A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform prior to beginning the procedure? Select all.
- A. Review a signal the client can use if feeling any distress.
- B. Lay a towel across the client's chest.
- C. Administer oral pain meds.
- D. Obtain a Dobhoff tube for insertion.
- E. Have a petroleum-based lubricant available.
Correct Answer: A, B
Rationale: Correct Answer: A, B
Rationale:
A: Review a signal the client can use if feeling any distress - This is important to ensure the client can communicate any discomfort or issues during the procedure.
B: Lay a towel across the client's chest - Helps protect the client's clothing and bedding from potential spillage during the procedure.
C: Administer oral pain meds - Not necessary prior to NG tube insertion for gastric decompression.
D: Obtain a Dobhoff tube for insertion - Dobhoff tube is not typically used for gastric decompression with NG tube.
E: Have a petroleum-based lubricant available - Lubricant is required for NG tube insertion but not specifically petroleum-based.
F:
G:
Summary: Choices C, D, and E are not necessary prior to beginning the NG tube insertion procedure. Choice A and B are essential steps to ensure patient safety and comfort during the process.
A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign this client?
- A. Charge nurse
- B. RN
- C. LPN
- D. AP
Correct Answer: B
Rationale: The correct answer is B: RN. A registered nurse (RN) is the most appropriate staff member to care for a client awaiting transfer from the PACU following thoracic surgery due to their advanced training and skill set. RNs are qualified to assess, monitor, and manage complex post-operative care needs, including respiratory status, pain management, and hemodynamic stability. Charge nurses may have administrative duties and may not be available to provide direct patient care. LPNs have a more limited scope of practice and may not have the necessary skills to care for a post-thoracic surgery patient. Advanced practice nurses (AP) typically have specialized roles and responsibilities that may not align with providing direct care in this situation.