Nokea
A client refuses to remove a religious necklace before surgery despite hospital policy. The nurse's best response is:
- A. Remove the necklace during transport.
- B. Tape the necklace securely to the client's chest.
- C. Insist the client comply with policy.
- D. Notify the surgeon to cancel the procedure.
Correct Answer: B
Rationale: Taping the necklace securely respects the client's beliefs while ensuring safety by preventing the item from interfering with the surgical field.
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The newly hired nurse cares for a client bitten by a venomous snake in the left hand. Which of the following interventions by the newly hired nurse requires follow-up by the charge nurse?
- A. Applying a tourniquet proximal to the bite.
- B. Removing the client's wristwatch and jewelry.
- C. Establishing intravenous (IV) access.
- D. Obtaining a type and crossmatch for fresh frozen plasma (FFP).
Correct Answer: A
Rationale: Applying a tourniquet can worsen tissue damage by restricting blood flow and concentrating venom, requiring follow-up. Removing jewelry (B) prevents constriction from swelling, establishing IV access (C) is essential for antivenom administration, and type and crossmatch (D) may be appropriate for potential complications.
A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed to avoid wrong-site surgery? Select all that apply.
- A. Ask the surgeon preoperatively to mark with a permanent marker the correct knee for the surgical site.
- B. Verbally ask the client to state his name, surgical site, and procedure.
- C. Verify the correct client with the correct operative site by medical records and radiographic diagnostic reports.
- D. Call a 'time-out' in the operating room to have the surgeon verify the correct knee before making the incision.
- E. Show the client an anatomic model of the surgery site.
Correct Answer: A,B,C,D
Rationale: To prevent wrong-site surgery, the surgeon marks the site (A), the client verifies identity and procedure (B), records are checked (C), and a time-out confirms the site (D). Showing a model (E) is educational but not a standard safety measure.
The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include? Select all that apply.
- A. Monitoring vital signs once a shift.
- B. Weighing the client daily.
- C. Changing the central venous line dressing daily.
- D. Monitoring the I.V. infusion rate hourly.
- E. Taping all I.V. tubing connections securely.
Correct Answer: B,C,D,E
Rationale: For a client on TPN, daily weight monitoring (B), daily dressing changes (C), hourly infusion rate checks (D), and securing tubing connections (E) are critical to prevent complications like infection or fluid imbalance. Vital signs once a shift (A) is insufficient; more frequent monitoring is needed. CN: Pharmacological and parenteral therapies; CL: Create
When teaching the diabetic client about foot care, the nurse should instruct the client to do which of the following?
- A. Avoid going barefoot.
- B. Buy shoes a half size larger.
- C. Cut toenails at angles.
- D. Use heating pads for sore feet.
Correct Answer: A
Rationale: Diabetic clients should avoid going barefoot to prevent foot injuries, which can lead to serious complications due to poor healing and neuropathy.
After cataract removal surgery, the client is instructed to report sharp pain in the operative eye because this could indicate which of the following postoperative complications?
- A. Detached retina.
- B. Prolapse of the iris.
- C. Extracapsular erosion.
- D. Intraocular hemorrhage.
Correct Answer: D
Rationale: Sharp pain in the operative eye post-cataract surgery may indicate intraocular hemorrhage, which can increase intraocular pressure and cause severe pain, requiring immediate intervention.