Nokea
A nurse is observing a client during an excretory urogram. Which of these observations indicate a complication is occurring?
- A. The client complains of a salty taste in the mouth when the dye is injected.'
- B. The client's entire body turns a bright red color.'
- C. The client states 'I have a feeling of getting warm.''
- D. The client gags and complains 'I am getting sick.''
Correct Answer: B
Rationale: The client's entire body turns a bright red color.' This observation suggests anaphylaxis which results in massive vasodilation. Other findings would be immediate wheezing and/or respiratory arrest.
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The clinic nurse encounters the client who has a congested cough and rhinorrhea. The nurse follows droplet precautions/cough protocol by taking which action? Select all that apply.
- A. Offering the client sterile disposable tissues
- B. Wearing a mask while examining the client
- C. Offering the client water to drink while waiting
- D. Teaching how to cover the mouth when coughing
- E. Performing hand hygiene before and after client contact
- F. Separating the client by at least 3 feet from others in the area
Correct Answer: B,D,E,F
Rationale: B: A mask is required during examination to prevent droplet transmission. D: Teaching cough etiquette reduces spread. E: Hand hygiene prevents pathogen transmission. F: Maintaining 3 feet distance reduces droplet spread. A: Sterile tissues are unnecessary. C: Water does not limit transmission.
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
- A. Blanch nail beds for color and refill
- B. Assess for post-operative arrhythmias
- C. Auscultate for pulmonary congestion
- D. Monitor equality of peripheral pulses
Correct Answer: B
Rationale: Assess for post-operative arrhythmias. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
- A. have the client identify coping methods
- B. get the description of the location and intensity of the pain
- C. accept the client's report of pain
- D. determine the client's status of pain
Correct Answer: C
Rationale: accept the client's report of pain. Although all of the options above are correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain -- 'the client's report.'
The client who is receiving TPN through a subclavian triple-lumen catheter expresses concern to the nurse about bacteria entering the blood through the catheter. The nurse explains that the risk of catheter-related infections can be decreased by taking which action?
- A. Applying an antibiotic ointment at the catheter insertion site daily
- B. Changing the dressing over the catheter insertion site every day
- C. Designating one port of the catheter exclusively for the TPN solution
- D. Instilling an antibiotic solution daily into each port of the catheter
Correct Answer: C
Rationale: C: Using one port exclusively for TPN reduces infection risk by limiting access points. A, D: Antibiotic use risks resistance. B: Daily dressing changes are unnecessary unless soiled.
The nurse is completing a variance report after finding a plastic bag at the nurse's station with contents and the sticker illustrated. The nurse should document finding a plastic bag with a symbol indicating that the contents of the bag include which type of item?
- A. Potentially infectious specimen
- B. Radioactive medication
- C. Flammable substance
- D. Poisonous substance
Correct Answer: A
Rationale: A: The biohazard symbol indicates potentially infectious material. B, C, D: Other symbols (trefoil, NFPA diamond) denote radiation, flammability, or toxicity.