Nokea
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?
- A. Explain to the client that the dentures must come out as they may get lost or broken in operating room
- B. Ask the client if there are second thoughts about having the procedure
- C. Notify the anesthesia department and the surgeon of the client's refusal
- D. Ask the client if the preference would be to remove the dentures in the operating room receiving area
Correct Answer: D
Rationale: Ask the client if the preference would be to remove the dentures in the operating room receiving area. Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client's sense of self-esteem and self-concept.
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After securing the client's safety from a faulty electric bed, the nurse should take which action?
- A. Discuss the matter with the client's significant others.
- B. Document the incident in the client's record in detail.
- C. Notify the physician.
- D. Prepare an incident report.
Correct Answer: D
Rationale: After the situation is safe for the client, the nurse should record the occurrence on an incident form according to the agency protocol.
The nurse is caring for the client who received afterload internal radiotherapy (brachytherapy) for treatment of uterine cancer. The nurse manager evaluates that the nurse uses correct hazardous material precautions when noting that the nurse takes which action?
- A. Double-bags linens before removing them from the client's room
- B. Minimizes the amount of time spent in contact with the client
- C. Maintains a distance of 1 foot away from the client
- D. Wears lead gloves and apron and a dosimetry badge with client contact
Correct Answer: B
Rationale: Minimizing time spent with the client reduces radiation exposure, a key precaution in brachytherapy.
Which of these clients is at highest risk for contracting a tuberculosis infection?
- A. A nurse who is immune-suppressed from chemotherapy
- B. A nursing student with a negative purified protein derivative (PPD) test
- C. An elderly client in a nursing home who has never been tested for TB
- D. A health care worker who has a positive PPD test but negative chest x-ray
Correct Answer: A
Rationale: The immune-suppressed nurse undergoing chemotherapy is at the highest risk for contracting tuberculosis due to a weakened immune system, which reduces the ability to fight infections like TB.
The nurse is to administer a new medication to a client. Which of these actions best demonstrate awareness of safe, proficient nursing practice?
- A. Verify the order for the medication. Prior to giving the medication the nurse should say, 'Please state your name.'
- B. Upon entering the room the nurse should ask: 'What is your name? What allergies do you have?' and then check the client's name band and allergy band.
- C. As the room is entered say 'What is your name?' then check the client's name band.
- D. Verify the client's allergies on the chart and confirm the client's name on the name band.
Correct Answer: B
Rationale: Asking the client to state their name and allergies, then verifying with the name band and allergy band, ensures accurate identification and safety.
The mother calls the nurse to ask when her newborn will be brought back to her room to finish feeding. The mother states that a doctor came about 30 minutes ago to take the baby for an examination and has not returned with her baby. Which action should be taken by the nurse first?
- A. Check the unit for the infant
- B. Initiate procedures for possible newborn abduction
- C. Ask other staff if they saw any physicians on the unit
- D. Check to see if the doctor is still examining the Infant
Correct Answer: B
Rationale: The suspicious circumstance of a doctor taking the baby for 30 minutes warrants immediate initiation of abduction procedures to ensure the newborn's safety.