Nokea
A client who is post-op following a partial colectomy has an NG tube set on low continuous suction. The client complains of a sore throat and asks when the NG tube will be removed. Which response by the nurse is appropriate at this time?
- A. When the GI tract is working again, in about three to five days, the tube can be removed.
- B. The tube will be removed once your nausea improves.
- C. You can expect the tube to be removed in about a week.
- D. The tube will be removed once the drainage stops.
Correct Answer: A
Rationale: The correct response is A: 'When the GI tract is working again, in about three to five days, the tube can be removed.' After a partial colectomy, the GI tract needs time to recover and start functioning properly. The NG tube is typically removed when peristalsis returns, indicating GI function restoration, which usually occurs within 3-5 days post-op. Choice B is incorrect because the removal of the NG tube is not solely based on nausea improvement. Choice C is incorrect as it provides a longer duration for tube removal than is usually necessary. Choice D is incorrect as the cessation of drainage alone does not dictate NG tube removal; the return of GI function is the primary indicator.
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A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing techniques?
- A. The nurse washes with her hands held higher than her elbows.
- B. The nurse uses a brush to scrub under her nails.
- C. The nurse washes for at least 30 seconds.
- D. The nurse uses alcohol-based hand rub only.
Correct Answer: A
Rationale: Proper surgical hand-washing technique involves keeping the hands higher than the elbows to prevent contamination. Washing with hands held lower than the elbows can lead to potential contamination. Using a brush to scrub under the nails is not recommended as it can cause microabrasions, increasing infection risk. While washing for at least 30 seconds is a good practice for thorough hand hygiene, hand positioning is critical during surgical hand-washing. Using alcohol-based hand rub alone is insufficient for surgical hand-washing as it may not effectively remove dirt, debris, and transient microorganisms.
An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?
- A. Help the client write down the questions to ask the provider, so that the client doesn't forget
- B. Reassure the client that everything will be explained
- C. Explain the procedure in detail yourself
- D. Direct the client to search for information online
Correct Answer: A
Rationale: Assisting the client in preparing questions is the most appropriate action as it helps ensure that all concerns are addressed during the provider's visit. By helping the client write down questions, the nurse empowers the client to actively participate in their care and communicate effectively with the provider. Reassuring the client, while well-intentioned, may not address the specific questions or fears the client has. Explaining the procedure in detail may not be what the client is seeking at this moment, as their primary concern is about the provider's actions. Directing the client to search for information online is not recommended as it may lead to confusion or misinformation, and the information may not be tailored to the client's specific situation.
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?
- A. Obtaining cotton balls for the tracheostomy care
- B. Using a sterile water bottle
- C. Checking the suction equipment
- D. Wearing a sterile gown
Correct Answer: A
Rationale: The correct answer is A. Obtaining cotton balls for tracheostomy care is not recommended due to the risk of fiber contamination. Sterile gauze should be used instead. Choice B, using a sterile water bottle, is a correct and appropriate action for tracheostomy care to maintain cleanliness. Choice C, checking the suction equipment, is also a necessary step to ensure it is functioning properly for the procedure. Choice D, wearing a sterile gown, is a standard precaution to maintain a sterile environment during tracheostomy care.
When teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses, what should the charge nurse instruct as the initial response in CPR?
- A. Confirm unresponsiveness
- B. Check for a pulse
- C. Begin chest compressions
- D. Call for emergency help
Correct Answer: A
Rationale: The correct initial response in CPR is to confirm unresponsiveness. This step is crucial to ensure that the person actually needs CPR before proceeding with further actions. Checking for unresponsiveness is essential to determine if the individual is in need of immediate assistance. Checking for a pulse or beginning chest compressions without confirming unresponsiveness could waste valuable time and potentially harm the individual. Calling for emergency help is important, but it should follow the confirmation of unresponsiveness to ensure timely activation of emergency services.
When should discharge planning for a patient admitted to the neurological unit with a diagnosis of stroke begin?
- A. At the time of admission
- B. The day before the patient is to be discharged
- C. When outpatient therapy is no longer needed
- D. As soon as the patient's discharge destination is known
Correct Answer: A
Rationale: Discharge planning for a patient admitted to the neurological unit with a stroke diagnosis should begin at the time of admission. Initiating discharge planning early allows for a comprehensive assessment of the patient's needs, enables better coordination of care, and ensures a smooth transition from the hospital to the next level of care. Option B is incorrect because waiting until the day before discharge does not provide enough time for adequate planning. Option C is incorrect because waiting until outpatient therapy is no longer needed delays the planning process. Option D is incorrect because waiting until the discharge destination is known may result in rushed planning and inadequate preparation for the patient's needs.