Nokea
A health care provider (HCP) orders the immediate use of a piece of electrical care equipment for a client. When the nurse goes to use the piece of equipment, the nurse immediately suspects it may be faulty. The nurse should take which initial action?
- A. Try the piece of electrical care equipment and see if it becomes hazardous.
- B. Call the health care provider and report your suspicion.
- C. Ask the client if they want you to try the piece of electrical care equipment.
- D. Immediately remove the piece of electrical care equipment from service.
Correct Answer: D
Rationale: Removing faulty equipment from service prevents harm, the priority action. Trying it, consulting the client, or calling the provider delays safety measures.
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The nurse is caring for a client with an indwelling urinary catheter connected to a drainage bag. The nurse demonstrates effective care when. Select all that apply.
- A. Emptying the drainage bag when it is half full.
- B. Collecting a urine specimen for culture from the port in drainage tubing.
- C. Clamping the urinary catheter tubing prior to discontinuation.
- D. Instructing the client to carry the collection bag above their bladder during ambulation.
- E. The tubing goes in and out of the urethra during cleaning.
Correct Answer: A,B
Rationale: Emptying when half full prevents reflux, and collecting from the port ensures sterility. Clamping is unnecessary, carrying above the bladder risks reflux, and tubing movement risks infection.
The purpose of a health assessment is to:
- A. Obtain subjective and objective data
- B. Outline appropriate care
- C. Determine whether interventions are effective
- D. Intervene to correct difficulties
Correct Answer: A
Rationale: Health assessments collect subjective and objective data to inform care planning. Outlining care, evaluating interventions, or correcting issues are subsequent steps.
The nurse is caring for a client immediately following hypophysectomy. The nurse should position the client
- A. Trendelenburg
- B. Side-lying
- C. high-Fowler's
- D. Reverse Trendelenburg
Correct Answer: C
Rationale: High-Fowler’s position (head elevated 30–45 degrees) is recommended post-hypophysectomy to reduce intracranial pressure and prevent cerebrospinal fluid leakage. Trendelenburg and reverse Trendelenburg could increase pressure or disrupt surgical site healing, and side-lying is less effective for this purpose.
The nurse is preparing to provide care for a client with disseminated herpes zoster. The nurse plans to don which personal protective equipment (PPE)? Select all that apply.
- A. Goggles
- B. Gown
- C. Gloves
- D. Shoe covers
- E. N95 respirator
- F. Surgical face mask
Correct Answer: B,C,E
Rationale: Disseminated herpes zoster requires airborne and contact precautions, necessitating a gown, gloves, and N95 respirator. Goggles, shoe covers, and surgical masks are insufficient.
The nurse performs a home safety survey for an individual with epilepsy. Click to specify the findings that require intervention by the nurse
- A. Multiple glass tables in the living room
- B. Multiple feather pillows present on the bed
- C. Padded covers on the edges of countertops
- D. Wall-to-wall carpeting was removed and replaced with scattered rugs on hardwood flooring
- E. Kitchen knives were readily accessible
- F. Client reports using the microwave instead of the stove
- G. Locks on the bathroom door
Correct Answer: A,D,E,G
Rationale: Glass tables, scattered rugs, accessible knives, and bathroom locks pose injury risks during seizures, requiring intervention.