Nokea
A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who is ambulatory and receiving oxygen
- B. A client who has a fracture and is in balance suspension traction
- C. A client who is bedridden and wears a hearing aid
- D. A client who uses a wheelchair and is confused
Correct Answer: A
Rationale: The correct answer is A: A client who is ambulatory and receiving oxygen should be evacuated first during a fire. This client has the highest risk due to the combination of mobility impairment and oxygen use, which increases the potential for rapid deterioration in a fire emergency. Oxygen supports combustion, making this client more vulnerable to fire-related injuries.
Choice B: A client with a fracture in balance suspension traction is stable and can wait for evacuation. Choice C: A bedridden client with a hearing aid can still hear evacuation instructions and wait for assistance. Choice D: A confused client in a wheelchair may require assistance but is not at immediate risk like the ambulatory client with oxygen.
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The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
Correct Answer: B
Rationale: The correct answer is B: Place a container for soiled linens inside the client's room. This intervention is important to prevent the spread of infection. Placing a container for soiled linens inside the client's room ensures that contaminated linens are contained and not mixed with other linens, reducing the risk of transmitting the infection to others.
Rationale for why other choices are incorrect:
A: Wearing an N95 mask is not necessary unless the client has airborne precautions, such as tuberculosis.
C: Placing the client in a negative airflow room is typically reserved for clients with airborne infections to prevent the spread of droplet nuclei in the air.
D: Removing the mask after exiting the client's room is incorrect as the mask should be removed before exiting to prevent contamination outside the room.
In summary, choice B is correct as it directly addresses infection control measures related to soiled linens, while the other choices are not relevant to isolation precautions or are incorrect based on standard
A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching?
- A. I know that I can change my advance directives if needed in the future.
- B. My healthcare proxy will make decisions as soon as I sign the power of attorney.
- C. My family can overrule the decisions made by my healthcare proxy.
- D. Advance directives from one state are valid in any other state.
Correct Answer: A
Rationale: Rationale: Option A is correct because it shows the client understands that advance directives can be modified. This is crucial as preferences may change over time. Option B is incorrect as the healthcare proxy only makes decisions when the client cannot. Option C is incorrect as the healthcare proxy's decisions are legally binding. Option D is incorrect because advance directives must comply with state laws and may not be universally recognized.
A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take?
- A. Position the client on the affected side for 4 hr following the procedure.
- B. Instruct the client to avoid coughing during the procedure.
- C. Inform the client that he will be NPO for 6 hr prior to the procedure.
- D. Place the client in the prone position during the procedure.
Correct Answer: B
Rationale: Correct Answer: B - Instruct the client to avoid coughing during the procedure.
Rationale: Coughing during thoracentesis can increase the risk of complications such as lung puncture or bleeding. Instructing the client to avoid coughing helps maintain safety during the procedure by minimizing these risks.
Incorrect Choices:
A: Positioning the client on the affected side for 4 hours following the procedure is not necessary and may not be beneficial. It does not directly impact the safety or success of the thoracentesis.
C: NPO for 6 hours prior to the procedure is not typically required for a thoracentesis. This action is more common for procedures involving anesthesia or sedation.
D: Placing the client in the prone position during the procedure is not recommended for thoracentesis. The client is usually positioned upright or slightly leaning forward to facilitate the procedure.
A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
- A. I will wait 15 minutes after drinking coffee to measure my blood pressure.
- B. I will measure my blood pressure while my arm is elevated above my heart.
- C. I should remove constrictive clothing prior to measuring my blood pressure.
- D. I should measure my blood pressure immediately after eating breakfast.
Correct Answer: C
Rationale: The correct answer is C because removing constrictive clothing prior to measuring blood pressure helps ensure accurate readings. Tight clothing can artificially elevate blood pressure readings. Choice A is incorrect because waiting 15 minutes after drinking coffee doesn't impact blood pressure measurement accuracy. Choice B is incorrect because the arm should be at heart level, not elevated. Choice D is incorrect because blood pressure should be measured on an empty stomach for consistency.
A nurse is performing postmortem care for a recently deceased client prior to the client's family viewing. Which of the following actions should the nurse take?
- A. Cross the client's arms across their chest.
- B. Hold the client's eyes shut for a few seconds.
- C. Place the client in a high-Fowler's position.
- D. Remove the client's dentures from their mouth.
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is appropriate because it helps create a peaceful appearance for the deceased client, providing a more dignified and comforting view for the family during the viewing. Holding the eyes shut is a common practice to maintain a natural appearance and show respect for the deceased.
Crossing the client's arms (Choice A) is not necessary and may not be culturally appropriate for all families. Placing the client in a high-Fowler's position (Choice C) is not recommended as it may not be comfortable or appropriate for viewing. Removing the client's dentures (Choice D) is also unnecessary and may not be respectful to the deceased.