Nokea
Which of the following actions should the nurse plan to take?
- A. Position the client on the affected side for 4 hr following the procedure
- B. Instruct the client to avoid coughing during the procedure
- C. Inform the client that he will be NPO for 6 hr prior to the procedure
- D. Place the client in the prone position during the procedure,
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to avoid coughing during the procedure. This is crucial because coughing can disrupt the procedure, leading to potential complications. Coughing can cause movement that may interfere with the accuracy of the procedure or cause injury to the client. Positioning the client on the affected side (A) for 4 hours following the procedure is not necessary and can lead to discomfort. Informing the client that they will be NPO for 6 hours prior to the procedure (C) may not be relevant depending on the type of procedure. Placing the client in the prone position during the procedure (D) can be risky and uncomfortable for the client.
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A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs
- D. Apply, an orthotic to the client's foot
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. This intervention helps to maintain proper alignment of the foot, preventing contractures that can occur due to prolonged immobility. Placing a pillow under the client's knees (choice A) is beneficial for reducing pressure on the lower back but does not specifically address foot contractures. Similarly, placing a towel roll under the client's neck (choice B) is helpful for neck support but does not prevent foot contractures. Aligning a trochanter wedge between the client's legs (choice C) is aimed at hip alignment and not foot contractures. Therefore, the most appropriate intervention to prevent foot contractures in an immobile client is applying an orthotic to the client's foot.
Select the 5 findings that require immediate follow-up
- A. Stool results
- B. Hemoglobin and Hematocrit
- C. Respiratory rate
- D. Heart rate
- E. Current medications
- F. Temperature
- G. WIC count
Correct Answer: A,B,D,E,H
Rationale: The correct choices for immediate follow-up are A, B, D, E, and H. Stool results (A) are crucial for detecting gastrointestinal issues. Hemoglobin and hematocrit (B) levels indicate blood health. Heart rate (D) reflects cardiovascular function. Current medications (E) help assess potential drug interactions. WIC count (H) is essential for monitoring infection. Respiratory rate (C) and temperature (F) are important but not as urgent.
A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following activities should the nurse perform first?
- A. Administer an antiemetic medication.
- B. Evaluate functioning of the suction device.
- C. Provide oral hygiene care
- D. Replace the NG tube.
Correct Answer: B
Rationale: The correct answer is B: Evaluate functioning of the suction device. First, the nurse needs to ensure proper suction to prevent aspiration and maintain airway patency. This step is crucial for the client's safety and well-being. Administering an antiemetic medication (A) may be necessary but not the first priority. Providing oral hygiene care (C) can wait until after ensuring proper suction. Replacing the NG tube (D) is not necessary unless there are signs of tube malfunction.
For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.
- A. Perform suctioning
- B. Assess for urinary retention.
- C. Assess blood pressure every 15 min
- D. Withhold pain medication for headache until other manifestations resolve.
- E. Place client in supine position
- F. Administer nifedipine.
Correct Answer:
Rationale: Rationales provided within the question context.
The nurse observes blood on the child's dressing.Which of the following actions should the nurse take?
- A. Apply intermittent pressure 2.5 cm(1 in) below the percutaneous skin site
- B. Apply continuous pressure 2.5 cm(1 in) above the percutaneous skin site
- C. Apply continuous pressure 2.5 cm(1 in) below the percutaneous skin site.
- D. Apply intermittent pressure 2.5 cm(1 in) above the percutaneous skin site
Correct Answer: B
Rationale: Continuous pressure above the site controls bleeding effectively.