Nokea
Which of the following interventions should the nurse include?
- A. Assess the child for frequent swallowing
- B. Carefully suction the child's oropharynx to remove secretions
- C. Administer pancreatic enzymes with meals
- D. Continuously monitor the child's respiratory status
Correct Answer: A
Rationale: Frequent swallowing indicates airway obstruction risks.
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A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has epidural analgesia and weakness in the lower extremities
- B. A client who has a hip fracture and a new onset of tachypnea
- C. A client who has sinus arrhythmia and is receiving cardiac monitoring
- D. A client who has diabetes mellitus and an HbA1c of 6.8%
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client with a hip fracture and new onset of tachypnea first. Tachypnea in this client could indicate a potential complication such as a pulmonary embolism, which is a life-threatening condition requiring immediate intervention. Assessing this client first allows for prompt identification and management of any emergent issues. Clients with epidural analgesia and lower extremity weakness (choice A) may indicate a neurological concern but are not as urgent as tachypnea in a client with a hip fracture. Sinus arrhythmia with cardiac monitoring (choice C) and diabetes mellitus with an HbA1c of 6.8% (choice D) do not present immediate life-threatening situations that require immediate assessment compared to the client with a hip fracture and tachypnea.
Which of the following examples should the nurse include in the teaching as an example of malpractice?
- A. Documenting communication with a provider in the progress notes of the client's medical record
- B. Placing a yellow bracelet on a client who is at risk for falls
- C. Leaving a nasogastric tube clamped after administering oral medication
- D. Administering potassium via IV bolus
Correct Answer: C
Rationale: The correct answer is C because leaving a nasogastric tube clamped after administering oral medication is an example of malpractice. This action can lead to obstruction and potential harm to the client. Documenting communication (A) is a standard practice to ensure accurate record-keeping. Placing a yellow bracelet (B) is a safety measure. Administering potassium via IV bolus (D) is within the scope of practice if done correctly.
Which of the following statements should the nurse make?
- A. We can review some information to help you select a safe alternative practitioner.
- B. I there are therapies available to you, your provider will tell you about them.
- C. Feel free to try whatever therapies that fit within your personal belief system.
- D. I'm sure you can find alternative remedies through an online support group.
Correct Answer: A
Rationale: The correct answer is A because the nurse should offer to review information to assist the patient in selecting a safe alternative practitioner, showing support and guidance. Choice B is incorrect because it assumes the provider will inform the patient of therapies, not necessarily the nurse. Choice C is incorrect as it lacks professional guidance and may lead to unsafe choices. Choice D is incorrect as it suggests the patient can find remedies independently without professional advice.
Which of the following should the nurse use to access the port?
- A. An angiocatheter
- B. A 25-gauge needle
- C. A butterfly needle
- D. A noncoring needle
Correct Answer: D
Rationale: The correct answer is D: A noncoring needle. The nurse should use a noncoring needle to access the port because it is specifically designed for this purpose. Noncoring needles have a special tip that minimizes damage to the port septum, reducing the risk of complications such as infection or port damage. An angiocatheter (A) is not ideal for accessing a port as it is designed for venipuncture, not for accessing ports. A 25-gauge needle (B) may be too small and may not provide adequate flow. A butterfly needle (C) is not recommended for accessing ports due to its design and potential for septum damage.
Which of the following actions should the nurse Include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
- A. Use a face shield with a mask when providing care to the client.
- B. Tell the client.You seem to be very upset.""
- C. Engage the panic alarm:
- D. Initiate seclusion protocol
Correct Answer: B
Rationale: The correct answer is B because acknowledging the client's emotions can help de-escalate the situation. By stating, "You seem to be very upset," the nurse shows empathy and understanding, which can help the client feel heard and validated. Using a face shield, engaging the panic alarm, or initiating seclusion protocol are not appropriate actions in this scenario as they do not address the client's emotional state or help in calming them down. Face shield and panic alarm are more related to safety precautions, while seclusion protocol should only be considered as a last resort for safety reasons. Therefore, choice B is the most appropriate action for interacting with a client who is aggravated, pacing, and speaking loudly.