Nokea
A nurse identifies an extravasation of a vesicant solution at a client's peripheral IV catheter's insertion site. Identify the sequence in which the nurse should perform the following actions.
- A. Aspirate the solution from the catheter.
- B. Stop the infusion.
- C. Disconnect the tubing from the catheter.
- D. Remove the IV catheter.
- E. Attach a syringe to the catheter.
Correct Answer: B,E,A,C,D
Rationale: The correct sequence is B, E, A, C, D. First, stopping the infusion prevents further harm. Then, attaching a syringe helps to aspirate the vesicant solution. Aspirating the solution reduces tissue damage. Disconnecting the tubing prevents further exposure. Lastly, removing the IV catheter minimizes harm and promotes healing. Incorrect choices: A is incorrect as the solution should be aspirated after stopping the infusion. C is incorrect as disconnecting the tubing should come after aspirating the solution. D is incorrect as removing the IV catheter is the final step after all the previous actions have been completed.
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A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse ask to promote this discussion?
- A. What brought you to the hospital?
- B. Would you tell me about all of your medical issues?
- C. Do you want to talk about your health concerns?
- D. Would it help to discuss your feelings about this hospitalization?
Correct Answer: A
Rationale: The correct answer is A: "What brought you to the hospital?" This question is open-ended and encourages the client to share their reason for seeking medical care, providing valuable information for the nurse to assess the client's health needs. Choice B is too broad and may overwhelm the client. Choice C puts the onus on the client to initiate the discussion. Choice D focuses on emotions rather than the primary reason for the hospitalization.
A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?
- A. Measure from the client's heel to the gluteal fold.
- B. Measure the length of the client's feet.
- C. Measure from the client's heel to the popliteal space.
- D. Measure the client's ankle circumference.
Correct Answer: C
Rationale: The correct answer is C: Measure from the client's heel to the popliteal space. This is the correct action because knee-high antiembolic stockings should cover the area from the heel to just below the knee at the popliteal space. This measurement ensures proper sizing and compression effectiveness.
A: Measuring from the heel to the gluteal fold is incorrect as it would result in stockings that are too long and may impede circulation.
B: Measuring the length of the client's feet is irrelevant for determining the correct size of knee-high stockings.
D: Measuring the client's ankle circumference alone is insufficient for determining the appropriate length of knee-high stockings.
In summary, choice C is correct as it ensures the stockings fit properly, while the other choices are incorrect due to inaccuracies or irrelevance in determining the appropriate size for knee-high antiembolic stockings.
The family of a client who has died unexpectedly arrives immediately after the death. Which of the following actions should the nurse take?
- A. Ask the family to return after the staff cleans the body.
- B. Perform postmortem care so that the body is prepared for the funeral home.
- C. Have a clergy member present when the family first sees the client.
- D. Allow the family to view the body privately.
Correct Answer: D
Rationale: The correct answer is D: Allow the family to view the body privately. This is important as it allows the family to have closure, grieve, and say their goodbyes in a respectful and private manner. It also promotes a sense of dignity and respect for the deceased. Choice A is incorrect as it may delay the family's grieving process. Choice B is incorrect as postmortem care should be performed after the family has had a chance to view the body. Choice C may be helpful but is not as essential as allowing the family to view the body privately.
A provider prescribes isometric exercises for a client who has a knee injury. The nurse should instruct the client to expect which of the following results from completing these exercises regularly?
- A. Increased muscle strength and tone to reduce muscle wasting
- B. Muscle hypertrophy to compensate for decreased joint strength
- C. Promotion of venous stasis to reduce the risk of embolus formation
- D. Reduction in bone density loss to prevent osteoporosis
Correct Answer: A
Rationale: The correct answer is A: Increased muscle strength and tone to reduce muscle wasting. Isometric exercises involve muscle contraction without joint movement, which helps improve muscle strength and tone. This is crucial in preventing muscle wasting commonly seen in clients with knee injuries. Muscle hypertrophy (B) is more associated with resistance training, not isometric exercises. Promotion of venous stasis (C) is incorrect as isometric exercises actually promote circulation and reduce the risk of blood clots. Reduction in bone density loss (D) is not directly related to isometric exercises.
A nurse is caring for a client who ingested a poison and is now having seizures. Which of the following is the priority action the nurse should take?
- A. Maintain the patency of the client's airway.
- B. Identify the poison the client ingested.
- C. Measure the client's blood pressure.
- D. Position the client on her side.
Correct Answer: A
Rationale: Airway patency is the priority during seizures to prevent aspiration and ensure adequate oxygenation.