Nokea
A client scheduled for pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. Which therapeutic response should the nurse make to the client to provide reassurance?
- A. The procedure is somewhat painful, but there is minimal exposure to radiation.'
- B. Discomfort may occur with needle insertion, and there is minimal exposure to radiation.'
- C. There is very mild pain throughout the procedure, and the exposure to radiation is negligible.'
- D. There is usually no pain, although a moderate amount of radiation must be used to get accurate results.'
Correct Answer: B
Rationale: Pulmonary angiography involves minimal exposure to radiation. The procedure is painless, although the client may feel discomfort with insertion of the needle for the catheter that is used for dye injection. This information supports the fact that the other options are incorrect.
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A client on the psychiatric unit begins to pace and continuously wring hands, and the nurse notes the client's voice is becoming louder and angrier. Which action does the nurse take?
- A. Utilize an organized team to place the client in seclusion.
- B. Allow time in the client's private assigned room for reflection.
- C. Redirect the client to a quiet activity such as journaling.
- D. Assist the client to express feelings of anger and frustration.
Correct Answer: D
Rationale: Assisting the client to express feelings helps de-escalate agitation by addressing the underlying emotions, promoting safety and therapeutic communication. Seclusion is a last resort, reflection may not address acute agitation, and journaling may not be feasible in this state.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
- A. Apply a warm compress proximal to the site.
- B. Check for kinks in the tubing and raise the IV pole.
- C. Adjust the tape that stabilizes the needle.
- D. Flush with normal saline and recount the drop rate.
Correct Answer: B
Rationale: When encountering a slowed peripheral IV rate, the nurse should initially check for common factors affecting infusion rates. Factors such as the height of the IV bag, presence of kinks in the tubing, needle size or position, client blood pressure, fluid viscosity, and infiltration can impact the rate. It is crucial to ensure the tubing is free of any kinks and that the IV pole is at an appropriate height to facilitate proper flow by gravity. Applying warmth proximal to the site might help with venospasm, but this intervention should come after ensuring proper tubing flow. Adjusting the tape that stabilizes the needle or flushing with normal saline may be necessary later in the troubleshooting process, but these actions should follow checking for kinks and adjusting the IV pole height, which are less invasive interventions.
When assisting an older adult client to prepare to take a tub bath, which nursing action is most important?
- A. Check the bath water temperature.
- B. Shut the bathroom door.
- C. Ensure that the client has voided.
- D. Provide extra towels.
Correct Answer: A
Rationale: The most critical nursing action when assisting an older adult client in preparing for a tub bath is to check the bath water temperature. This step is essential to prevent burns or excessive chilling, prioritizing the client's safety. While ensuring privacy by shutting the bathroom door (option B), confirming that the client has voided (option C), and providing extra towels (option D) are all important for comfort and dignity, they are secondary to ensuring the client's safety during bathing. Therefore, checking the bath water temperature is the priority to safeguard the client's well-being and prevent potential injuries.
A client who has been newly diagnosed with tuberculosis (TB) is hospitalized and will be on respiratory isolation for at least 2 weeks. Which intervention is most appropriate in planning to prevent psychosocial distress in the client?
- A. Noting whether the client has visitors
- B. Instructing all staff members to not touch the client
- C. Giving the client a roommate with TB who persistently tries to talk
- D. Removing the calendar and clock in the room so that the client will not obsess about time
Correct Answer: A
Rationale: The nurse should note whether the client has visitors and social contacts because the presence of others can offer positive stimulation. Touch may be important to help the client feel socially acceptable. A roommate who insists on talking could create sensory overload. In addition, the client on respiratory isolation should be in a private room. The calendar and clock are needed to promote orientation to time.
A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit?
- A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case.
- B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
- C. There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act.
- D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.
Correct Answer: C
Rationale: The Good Samaritan Act protects healthcare professionals who provide care in good faith from malpractice claims, regardless of the client outcome. In this scenario, the nurse stopped at the scene voluntarily to render aid, which is protected under the Good Samaritan Act. This law shields individuals from legal liability when providing emergency care in good faith and without expectation of compensation. The Patient's Bill of Rights does protect clients, but in this case, the nurse's actions were protected by the Good Samaritan Act. Additionally, the state Board of Nursing would not likely revoke the nurse's license unless there was evidence of actions taken in bad faith or unreasonable care. The client would not win the lawsuit as the essential elements of malpractice, including duty, breach, causation, and damages, were not met in this situation.