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A client continuously calls out to the nursing staff when anyone passes the client’s door and asks them to do something in the room. The best response by the charge nurse would be to
- A. keep the client’s room door cracked to minimize the distractions
- B. assign 1 of the nursing staff to visit the client regularly
- C. reassure the client that 1 staff person will check frequently if the client needs anything
- D. arrange for each staff member to go into the client’s room to check on needs every hour on the hour
Correct Answer: B
Rationale: Assign 1 of the nursing staff to visit the client regularly. Regular, frequent, planned contact by 1 staff member provides continuity of care and communicates to the client that care will be available when needed.
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The nurse is caring for a client who has just returned from the operating room after a cholecystectomy. Which of these findings requires immediate follow-up by the nurse?
- A. A temperature of 100.4°F (38°C)
- B. Pulse rate of 110 beats per minute
- C. Respiratory rate of 24 breaths per minute
- D. Oxygen saturation of 88%
Correct Answer: D
Rationale: An oxygen saturation of 88% indicates hypoxia, requiring immediate intervention to prevent respiratory compromise.
A client has been placed in isolation because he is diagnosed with a contagious illness. The nurse should be aware that:
- A. Linens from the client's bed should be double-bagged.
- B. Meals should be served on washable dishes.
- C. Extensive isolation rarely causes psychological problems.
- D. Paper trays and plastic utensils prevent disease transmission.
Correct Answer: A
Rationale: Linens should be double-bagged. Isolation refers to techniques used to prevent or to limit the spread of infection. Some form of isolation has been used for centuries, whether to protect a high-risk person from exposure to pathogens or to prevent the transmission of pathogens from an infected person to others. Special handling of articles and linen soiled by any body fluid is indicated. These articles should be placed in impervious bags before they are removed from the client's bedside. Bagging in watertight containers is indicated to prevent exposure of personnel and contamination of the environment. The outside of the bag should not be contaminated when placing articles inside it. Each hospital and community agency has procedures for labeling and decontaminating exposed articles. Items that are visibly soiled with body substances should be rinsed and placed in plastic bags or clearly marked containers, often labeled 'Contaminated.' If the outside of the bag becomes contaminated, placing that bag in another bag (double-bagging) is required.
In a disaster, triage situation, the nurse should be least concerned with which of the following regarding a client in crisis?
- A. ability to breathe
- B. pallor or cyanosis of the skin
- C. number of accompanying family members
- D. motor function
Correct Answer: C
Rationale: The least important factor (of those listed) during an emergency situation is the number of accompanying family members.
The client with DM is receiving care in the home for a foot ulcer. The home health nurse documents the narrative note illustrated. Which problem should be the nurse's priority on the return visit?
- A. Impaired skin integrity related to left foot ulcer
- B. Potential for injury related to improper footwear
- C. Potential altered nutrition: less than body requirements related to nausea
- D. Ineffective therapeutic regimen management related to not taking medications as prescribed
Correct Answer: B
Rationale: Improper footwear increases the risk of injury or falls, which is critical for a diabetic client with reduced foot sensation and a healing ulcer.
The nurse is performing a physical examination of a 3 month-old with a suspected heart murmur. Which assessment should be performed first?
- A. Inspect the chest
- B. Auscultate the mass
- C. Percuss the mass
- D. Palpate the mass
Correct Answer: B
Rationale: Auscultate the mass. Auscultation of the chest to listen for a heart murmur is the first step in confirming the presence of a murmur and guides further assessment.