Nokea
A client with a history of confusion has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client?
- A. Good morning. Do you remember where you are?
- B. Hello, my name is Susan Jones and I am your nurse for today.
- C. How are you today? Remember, you're in the hospital.
- D. Good morning. You're in the hospital. I am your nurse, Susan Jones.
Correct Answer: D
Rationale: A clear, concise statement of location and nurse identity provides effective reality orientation without challenging the client’s memory. Other options are less direct or confrontational.
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The nurse is caring for a client with a tracheostomy who requires suctioning. Which of the following actions by the nurse would indicate correct technique?
- A. Using a size 16 Fr catheter to suction the client.
- B. Withdrawing the suction catheter 1 to 2 cm before applying suction.
- C. Using 160 mm Hg of pressure when suctioning the client.
- D. Applying suction to the catheter for 25 seconds during withdrawal.
Correct Answer: B
Rationale: Withdrawing the catheter 1-2 cm before suctioning prevents mucosal trauma. A 16 Fr catheter may be too large, 160 mm Hg is excessive (80-120 mm Hg is typical), and suctioning for 25 seconds is too long (≤10-15 seconds).
The nurse cares for a client in the outpatient surgical center who is scheduled for a cholecystectomy
Item 1 of 1
Nurses' Note
0730 – The client arrives at the preoperative area with his family. He reports that he is anxious about the procedure. The pre-operative assessment was completed at this time. 20-gauge peripheral vascular access established in the right antecubital space. + blood return and flushes without resistance. The client reports no pain at the insertion site.
The nurse reviews the completed pre-operative assessment.Select the findings on the assessment that require follow-up
- A. ID verified and band applied
- B. The surgeon has not obtained informed consent
- C. Client took his prescribed phenytoin with a sip of water this morning
- D. The client reports his last meal and fluid intake was the previous day at 2200
- E. The client stated he was going to drive himself home after the procedure
Correct Answer: B,D
Rationale: Assessment items requiring follow-up include the informed consent not yet obtained by the surgeon. Before further preoperative activities may continue, the nurse must ensure this is completed to avoid unnecessary diagnostic testing and intervention. Additionally, the client will not be permitted to drive themselves home after this procedure because this involves general anesthesia. Activities requiring significant concentration, operation of heavy machinery, or driving are typically prohibited 24 hours following the initiation of general anesthesia.
The other assessment findings do not require intervention. ID banding and verification are expected during the preoperative process. The client's ID will also be verified in the intraoperative and postoperative processes. Medications such as phenytoin can be taken with a sip of water to prevent seizure activity. The client has been NPO for approximately eight hours, sufficient time to prevent aspiration.
The nurse observes that a fire has ignited in the client's room. After removing the client from the room, the nurse should then
- A. activate the fire alarm.
- B. extinguish the fire.
- C. contact the nursing supervisor.
- D. close the door to the client's room.
Correct Answer: A
Rationale: Following the RACE protocol (Rescue, Alarm, Contain, Extinguish), after rescuing the client, the nurse should activate the fire alarm to alert others and initiate emergency response.
The nurse is part of an infection control committee that is responding to an outbreak of norovirus in the long-term care facility. Which recommendation should the nurse make to prevent further transmission of this outbreak?
- A. Clients wear surgical masks while ambulating in the hallway.
- B. Replace boxes of clean gloves with sterile gloves.
- C. Review hand hygiene expectations with dietary staff.
- D. Screen visitors for any respiratory symptoms such as cough or fever.
Correct Answer: C
Rationale: Norovirus spreads via fecal-oral route, so reinforcing hand hygiene, especially among dietary staff, is critical. Masks, sterile gloves, and respiratory screening are less relevant.
The nurse is preparing to administer an enema to a client. Prior to administering this medication, the nurse should position this client
- A. Trendelenburg's position.
- B. Semi-Fowler's position.
- C. Left lateral position.
- D. Right lateral with the head of the bed lowered.
Correct Answer: C
Rationale: The left lateral position allows the enema solution to flow into the sigmoid colon via gravity. Other positions are less effective or impractical.