Nokea
A healthcare professional is providing teaching to a client who had a new medication prescription. Which of the following manifestations of a mild allergic reaction should the professional include?
- A. Urticaria
- B. Ptosis
- C. Nausea
- D. Hematuria
Correct Answer: A
Rationale: Urticaria, also known as hives, is a common manifestation of a mild allergic reaction. It presents as raised, red, itchy welts on the skin. Ptosis is drooping of the upper eyelid and is not typically associated with allergic reactions. Nausea is a gastrointestinal symptom that can occur with various conditions but is not specific to allergic reactions. Hematuria, which is the presence of blood in the urine, is not a typical manifestation of an allergic reaction.
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At the surgical scrub sink, a surgical nurse demonstrated the proper surgical handwashing technique by scrubbing:
- A. With her hands held lower than her elbows
- B. With her hands held higher than her elbows
- C. With her hands in a fist position
- D. With hands placed on her chest
Correct Answer: B
Rationale: The correct technique for surgical handwashing involves scrubbing with hands held higher than the elbows. This positioning helps prevent water from the contaminated area (the hands) from flowing towards the cleaner area (the elbows). This directional flow minimizes the risk of contaminating the scrubbed hands during the handwashing process. Choices A, C, and D are incorrect: A - having hands lower than elbows would risk contamination of the clean area, C - using a fist position does not ensure proper coverage and thorough handwashing, and D - placing hands on the chest is not part of the proper surgical handwashing technique.
When responding to a call light and finding a client on the bathroom floor, what should the nurse do FIRST?
- A. Check the client for injuries
- B. Call for additional help
- C. Move the client to a sitting position
- D. Assist the client back to bed
Correct Answer: A
Rationale: Checking the client for injuries is the priority when finding them on the bathroom floor. This action ensures the client's safety as it allows for immediate assessment of any potential harm. Calling for help may be necessary, but assessing for injuries takes precedence to address any immediate threats to the client's well-being. Moving the client to a sitting position or assisting them back to bed should only be done after ensuring there are no serious injuries requiring prompt medical attention. Therefore, the correct first action is to check the client for injuries.
During an assessment, a nurse is evaluating the breath sounds of an adult client diagnosed with pneumonia. Which of the following actions should the nurse take?
- A. Follow a systematic pattern from side-to-side moving down the client's chest.
- B. Ask the client to breathe in deeply through their nose.
- C. Instruct the client to sit upright with their head slightly tilted backward.
- D. Place the diaphragm of the stethoscope on the client's chest.
Correct Answer: A
Rationale: When assessing breath sounds in a client with pneumonia, the nurse should follow a systematic pattern from side-to-side moving down the client's chest. This approach ensures a comprehensive evaluation of breath sounds across different lung fields. Asking the client to breathe in deeply through their nose (Choice B) is not necessary for assessing breath sounds. Instructing the client to sit upright with their head slightly tilted backward (Choice C) is not directly related to assessing breath sounds and may not be required. Placing the diaphragm of the stethoscope on the client's chest (Choice D) is not the correct technique for auscultating breath sounds, as the diaphragm should be used for this purpose.
A healthcare professional is preparing information for a change-of-shift report. Which of the following information should the healthcare professional include in the report?
- A. Input and output measurements for the shift
- B. Blood pressure readings from the previous day
- C. Bone scan scheduled for today
- D. Medication regimen from the medication administration record
Correct Answer: D
Rationale: During a change-of-shift report, healthcare professionals should include the medication regimen from the medication administration record. This information ensures continuity of care and helps incoming staff understand the patient's medication needs and schedule. While input and output measurements, blood pressure readings, and scheduled procedures like a bone scan are important aspects of patient care, they may not be immediately relevant for the incoming shift. Focusing on medication details helps prevent errors and ensures the patient receives the correct medications at the right times.
A client has restraints on each extremity. Which of the following assessments should the nurse perform first?
- A. Peripheral pulses
- B. Comfort level
- C. Elimination needs
- D. Skin integrity
Correct Answer: A
Rationale: When a client is restrained, the nurse should prioritize assessing peripheral pulses first. This assessment is crucial to monitor circulation and ensure the restraints are not impeding blood flow. Comfort level, elimination needs, and skin integrity are also important assessments; however, assessing peripheral pulses takes precedence to prevent complications such as impaired circulation and tissue damage. By assessing peripheral pulses initially, the nurse can promptly identify and address any circulation issues, which are critical in preventing serious complications.