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A nurse is admitting a client to a healthcare facility. The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
- E. Wear a sterile water-resistant gown if within 3 feet of the client.
Correct Answer: A, B, C, E
Rationale: The correct answers are A, B, C, and E.
A: Wearing an N95 mask is crucial to prevent the spread of airborne infections.
B: Placing a container for soiled linens inside the room prevents contamination of other areas.
C: Placing the client in a negative airflow room helps contain infectious particles.
E: Wearing a gown within 3 feet of the client prevents exposure to bodily fluids.
D: Removing the mask after exiting the room increases the risk of contamination.
False options would include not utilizing an N95 mask, not isolating soiled linens, not placing the client in a negative airflow room, and not wearing appropriate PPE when close to the client.
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A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?
- A. Image A: Client sitting with legs dangling over the edge of the table and the examiner tapping below the patella with a reflex hammer.
- B. Image B: Client lying down with legs extended and the examiner tapping above the patella with a reflex hammer.
- C. Image C: Client sitting with legs crossed while the examiner taps the patella with a reflex hammer.
- D. Image D: Client standing with knees slightly bent while the examiner taps the patella with a reflex hammer.
Correct Answer: A
Rationale: The correct answer is A because the image depicts the correct technique for eliciting the patellar reflex. When assessing the patellar reflex, the client should be sitting with their legs dangling over the edge of the table, and the examiner should tap below the patella with a reflex hammer. This position allows for optimal relaxation of the quadriceps muscle and easy access to the patellar tendon, resulting in a more accurate reflex response.
Choice B is incorrect because tapping above the patella can lead to an inaccurate response as it does not target the patellar tendon directly. Choices C and D are incorrect as they involve incorrect client positions that do not facilitate the proper assessment of the patellar reflex.
A nurse is caring for a client who has pancreatitis. Select the 3 tasks the nurse should delegate to an assistive personnel (AP). First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia, Pulses to lower extremities weak with +2 dependent edema present, Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this am. States voiding without difficulty, clear yellow urine. Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle changes for heart failure. Provided medication teaching following provider's increase in furosemide dosage from.
- A. Document the client's vital signs.
- B. Measure the client's intake and output.
- C. Transfer the client from wheelchair to bed.
- D. Insert an NG tube for the client.
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Documenting vital signs is within the scope of practice for an assistive personnel (AP) as it involves measuring and recording objective data.
B: Measuring intake and output is a task that can be safely delegated to the AP as it requires basic monitoring skills and doesn't involve complex decision-making.
C: Transferring the client from a wheelchair to bed is a physical task that can be delegated to the AP, as long as proper body mechanics are used to prevent injury.
Summary:
D: Inserting an NG tube is a skilled nursing task that requires specialized training and should not be delegated to an AP.
E: No task provided for this option.
F: No task provided for this option.
G: No task provided for this option.
A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?
- A. Stir the needle to 15° before administration.
- B. Aspire the syringe prior to administration.
- C. Administer the medication to the abdomen.
- D. Massage the site following the injection.
Correct Answer: C
Rationale: Correct Answer: C - Administer the medication to the abdomen.
Rationale: Heparin is typically administered subcutaneously. The abdomen has a larger subcutaneous tissue area compared to other sites, allowing for better absorption and reducing the risk of tissue damage. Administering heparin in the abdomen also minimizes the risk of hitting blood vessels and nerves. It is important to rotate injection sites to prevent tissue damage and ensure consistent absorption.
Summary of other choices:
A: Stirring the needle to a specific angle is unnecessary and can increase the risk of needle breakage or improper administration.
B: Aspiration is not required for subcutaneous injections as it may cause unnecessary tissue trauma.
D: Massaging the site after injection can lead to bruising and discomfort.
E, F, G: Choices left blank as they are not relevant to the administration of heparin.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
- A. I think I should take my pain medication more often
- B. since it is not controlling my pain.
- C. Breathing faster will help me keep my mind off of the pain.
- D. It might help me to listen to music while I'm lying in bed.
- E. I don't want to walk today because I have some pain.
Correct Answer: C
Rationale: The correct answer is C. The client's statement about breathing faster to keep their mind off the pain indicates understanding of distraction techniques taught preoperatively. This method helps manage pain perception. Choices A and B suggest incorrect self-medication adjustments. Choices D and E do not demonstrate understanding of pain management strategies.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
- A. Position the client at the head of the bed elevated to 30° prior to insertion of the NG tube.
- B. Remove the NG tube if the client begins to gag or choke.
- C. Apply suction to the NG tube prior to insertion.
- D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Having the client take sips of water serves to promote the insertion of the NG tube into the esophagus by facilitating swallowing and opening the esophageal sphincter, making it easier to pass the tube through. This action helps ensure proper placement of the tube in the stomach without risking insertion into the trachea or lungs.
Summary of other choices:
A: Positioning the client at the head of the bed elevated to 30° is important but is not directly related to the insertion of the NG tube.
B: Removing the NG tube if the client gags or chokes is incorrect as these are common responses during insertion, and removing the tube may lead to premature discontinuation.
C: Applying suction to the NG tube prior to insertion is unnecessary and may cause discomfort or damage to the mucosa.