Nokea
Which of the following actions should the nurse take?
- A. Keep visitors at least 6 feet(1.8 m) away from the client.
- B. Place the client's soiled bed linens in a biohazard bag outside the client's room.
- C. Wear an isolation gown when caring for the client.
- D. Discard the radioactive source in the client's trash can.
Correct Answer: B
Rationale: The correct answer is B: Place the client's soiled bed linens in a biohazard bag outside the client's room. This is the correct action to prevent the spread of infection, as soiled linens may contain infectious agents. Keeping visitors 6 feet away (choice A) is related to social distancing, not linens handling. Choice C, wearing an isolation gown, is important but not directly related to handling soiled linens. Discarding a radioactive source in the trash can (choice D) is unsafe and violates radiation safety protocols.
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Identify the sequence of steps the nurse should take?
- A. Close all nearby windows and doors
- B. Transport the client to another area of the nursing unit
- C. Use the unit's fire extinguisher to attempt to put out the fire
- D. Activate the facility's fire alarm system
Correct Answer: D
Rationale: The correct answer is D: Activate the facility's fire alarm system. This is the first step the nurse should take in case of a fire emergency to ensure the safety of all individuals in the facility. Activating the fire alarm alerts everyone in the building about the fire and prompts an immediate response from the fire department. Closing windows and doors (A) may help contain the fire but should not be the initial action. Transporting the client (B) could put them at risk and is not a priority. Using the fire extinguisher (C) should only be done if safe and appropriate, but activating the alarm is more crucial.
The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition. The action the nurse should take first is------followed by ----------
- A. evaluating the fetal heart rate tracing
- B. monitoring urine output
- C. Checking the client's blood pressure
- D. administering labetalol
- E. Starting the continuous IV infusion
- F. inserting an indwelling urinary catheter
Correct Answer: C,D
Rationale: The correct first action is to check the client's blood pressure (Choice C) as it is essential to assess the client's immediate physiological status. High blood pressure in obstetric patients can lead to severe complications. Administering labetalol (Choice D) is the next step if the blood pressure is elevated, as it is a commonly used medication to manage hypertension in pregnancy. Choices A, B, E, and F are important interventions but should be prioritized after addressing the client's blood pressure as they are not directly related to the immediate risk of hypertensive crisis.
Which statement should the nurse include in the teaching?
- A. The test should be performed after your baby is 24 hours old.
- B. Genetic screening is only necessary if there is a family history of genetic disorders.
- C. Your baby cannot eat before the genetic screening test.
- D. If the first test is abnormal, no further testing is needed.
Correct Answer: A
Rationale: The correct answer is A because it accurately states the timing for performing the genetic screening test, which should be after the baby is 24 hours old to ensure accurate results. Choice B is incorrect because genetic screening may be recommended for all newborns, not just those with a family history. Choice C is incorrect because babies can eat before the test. Choice D is incorrect as further testing may be required if the initial results are abnormal.
The nurse should identify which of the following situations as an example of interpersonal conflict?
- A. A nurse submits a complaint about another department's handoff reporting.
- B. A nurse feels stressed about an upcoming performance evaluation.
- C. A hospital policy change leads to disagreements among staff members.
- D. Two nurses disagree on how to handle a client's care plan.
Correct Answer: D
Rationale: The correct answer is D because it involves a conflict between two individuals, which is a key characteristic of interpersonal conflict. In this scenario, the conflict arises between two nurses regarding the client's care plan, indicating a disagreement in opinions or approaches. This type of conflict typically involves differences in perspectives, values, or goals between individuals. Choices A, B, and C do not involve direct conflicts between individuals but rather focus on complaints, stress, and policy disagreements that do not necessarily involve direct interpersonal conflicts. Therefore, option D is the most appropriate example of interpersonal conflict in this context.
Which of the following interventions should the nurse include in the plan?
- A. Speak in a neutral tone when addressing the client.
- B. Force the client to take the prescribed medication.
- C. Encourage the client to discuss their delusions.
- D. Use humor to lighten the mood and build trust.
Correct Answer: A
Rationale: The correct answer is A: Speak in a neutral tone when addressing the client. This intervention is important as it helps maintain a calm and non-threatening environment, promoting effective communication with the client. Speaking in a neutral tone also conveys respect and understanding, which can help build trust and rapport.
Choice B is incorrect because forcing the client to take medication can lead to resistance and worsen the therapeutic relationship. Choice C may not be appropriate as encouraging a client to discuss delusions without proper training or expertise in addressing such issues could potentially exacerbate the situation. Choice D, using humor, may not be suitable in this context as it may not be well received by a client experiencing delusions.