Nokea
When unlicensed assistive personnel (UAP) assist a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidentally falls over and cracks. The UAP immediately report this incident to the nurse. What is the nurse's immediate action?
- A. Clamp the tube close to the client's chest until a new chest drainage unit is set up
- B. Notify the health care provider
- C. Place the distal end of the chest tube into a bottle of sterile saline
- D. Position the client on the left side
Correct Answer: C
Rationale: Placing the distal end of the chest tube in sterile saline maintains a water seal, preventing air from entering the pleural space until a new drainage unit is prepared.
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What is the major developmental task that the mother must accomplish during the first trimester of pregnancy?
- A. Acceptance of the pregnancy
- B. Acceptance of the termination of the pregnancy
- C. Acceptance of the fetus as a separate and unique being
- D. Satisfactory resolution of fears related to giving birth
Correct Answer: A
Rationale: Acceptance of the pregnancy. During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts.
The client has just returned from having a cast placed on the right forearm and is found putting a lead pencil in the cast to 'reach the itch.' What is the nurse's priority action?
- A. Offer the client a straw to reach the itch instead of a lead pencil
- B. Perform a peripheral neurovascular check of the casted extremity
- C. Pour a generous amount of baby powder or corn starch in the cast to reach the itch
- D. Review appropriate itch relief technique using the cool setting of a hair dryer
Correct Answer: D
Rationale: Using a hair dryer on a cool setting is a safe and effective way to relieve itching without risking skin damage or cast integrity, unlike inserting objects or powders.
A student nurse is preparing to administer the hepatitis B vaccine to a newborn. Which statement by the student nurse requires the preceptor to provide further teaching?
- A. A 5/8-inch, 25-gauge needle is appropriate for intramuscular injection in newborns.
- B. I will clean the injection site with an antiseptic swab before administration.
- C. I will draw the medication into a 1-mL syringe.
- D. The medication should be administered into the deltoid muscle.
Correct Answer: D
Rationale: The deltoid muscle is not developed enough in newborns for intramuscular injections. The hepatitis B vaccine should be administered in the anterolateral thigh.
When caring for a client with hypocalcaemia, the nurse should assess for:
- A. A decreased level of consciousness
- B. Tetany
- C. Bradycardia
- D. Respiratory depression
Correct Answer: B
Rationale: Hypocalcemia can cause tetany (muscle spasms or twitching) due to increased neuromuscular excitability.
The nurse on the telemetry unit is preparing client medications in the medication room. Which of the following actions should the nurse perform to be consistent with client safety practices related to medication administration? Select all that apply.
- A. Confirm the client's identity, medication, dosage, time, and route prior to medication administration
- B. Do not administer any medication that is damaged or has an unreadable label
- C. Place all medications in a dispensing cup before taking them to a client's room
- D. Review laboratory values before administering anticoagulants
- E. Wear gloves when handling transdermal medication patches
Correct Answer: A,B,D,E
Rationale: These actions align with safe medication administration practices: verifying the 'five rights' (A), ensuring medication integrity (B), checking relevant lab values for anticoagulants (D), and using gloves to prevent absorption of transdermal medications (E).