Nokea
A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?
- A. Dyspnea
- B. Pain at the surgical site
- C. Mild nausea
- D. Temperature of 37.5°C (99.5°F)
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Dyspnea in a postoperative client with a history of pulmonary embolism indicates a potential complication, such as a recurrent or new pulmonary embolism, which can be life-threatening. The nurse should report this finding to the provider immediately for further evaluation and intervention to prevent worsening respiratory distress and potential respiratory failure. Pain at the surgical site (choice B) is expected postoperatively and can be managed with appropriate pain medications. Mild nausea (choice C) is a common postoperative symptom and can be managed with antiemetic medications. A temperature of 37.5°C (99.5°F) (choice D) may indicate a mild fever, which can be monitored unless accompanied by other concerning symptoms.
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Which action should the nurse take?
- A. Identify possible precipitating factors related to the infection
- B. Reinforce proper hand hygiene practices among staff.
- C. Implement a protocol for timely removal of unnecessary catheters.
- D. Provide staff education on aseptic catheter insertion techniques.
- E. Conduct regular audits on catheter care compliance.
Correct Answer: E
Rationale: The correct action for the nurse to take is E: Conduct regular audits on catheter care compliance. Audits help monitor adherence to catheter care protocols, identify areas needing improvement, and ensure staff follow best practices consistently. This action promotes quality care, reduces infection risks, and enhances patient safety. Choices A, B, C, and D are important but do not directly address ongoing monitoring and assessment of compliance like regular audits do. Conducting audits is a proactive approach to continuously evaluate and improve catheter care practices, making it the most appropriate action in this scenario.
A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI(11) is intact when the client performs which of the following actions?
- A. Shrugs his shoulders
- B. Smiles symmetrically
- C. Closes his eyes tightly
- D. Identifies a familiar scent
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the accessory nerve, controls the movement of the trapezius and sternocleidomastoid muscles, which are responsible for shoulder shrugging. By asking the client to shrug his shoulders, the nurse can assess the integrity of cranial nerve XI.
Choices B, C, and D are incorrect because they are associated with other cranial nerves. Smiling symmetrically is controlled by cranial nerve VII (facial nerve), closing eyes tightly is controlled by cranial nerve V (trigeminal nerve), and identifying a familiar scent is related to cranial nerve I (olfactory nerve).
Which of the following actions should the nurse plan to take?
- A. Use a solution of 0.9% sodium chloride to flush the transfusion tubing.
- B. Prime the transfusion tubing with lactated Ringer's solution.
- C. Administer the transfusion through a 24-gauge IV catheter.
- D. Infuse the blood over a maximum of 6 hours.
Correct Answer: A
Rationale: The correct answer is A. Using a solution of 0.9% sodium chloride to flush the transfusion tubing is essential to ensure compatibility and prevent potential reactions between the blood product and other solutions. This is a standard practice to maintain the integrity of the blood product and prevent contamination. Flushing with lactated Ringer's solution (B) would introduce a different electrolyte composition that may affect the blood product. Administering the transfusion through a 24-gauge IV catheter (C) may not be appropriate for blood transfusions due to the risk of hemolysis or clotting. Infusing the blood over a maximum of 6 hours (D) is a general guideline for blood transfusions but is not the immediate action the nurse should plan to take.
Which intervention should the nurse include in the plan of care?
- A. Placing a formula in the container to last 18 hours
- B. Flushing the feeding tube with water every 4 to 6 hours.
- C. Covering and labeling the opened formula container with the date and time.
- D. Elevating the head of the bed to at least 30 degrees during feeding.
- E. Replacing the feeding container and tubing every 24 hours.
Correct Answer: E
Rationale: The correct answer is E, replacing the feeding container and tubing every 24 hours. This intervention is crucial to prevent bacterial contamination and ensure the patient's safety. By replacing the container and tubing regularly, the nurse helps maintain a sterile environment for the enteral feeding, reducing the risk of infection.
Choice A is incorrect because leaving formula in the container for 18 hours can lead to bacterial growth and contamination. Choice B, flushing the feeding tube with water every 4 to 6 hours, is important for tube patency but does not address the need for replacing the container and tubing. Choice C, covering and labeling the formula container, is a good practice for storage but does not address the need for regular replacement. Choice D, elevating the head of the bed during feeding, is important for preventing aspiration but is not directly related to the maintenance of feeding equipment.
A nurse is assessing a client who has historic personality disorder. Which of the following manifestations should the nurse expect?
- A. Suspicious of others
- B. Callousness
- C. self-centered behavior
- D. violates others rights
Correct Answer: C
Rationale: The correct answer is C: self-centered behavior. Individuals with historic personality disorder often display self-centered behavior as they prioritize their own needs and desires above others. This is due to their excessive need for admiration and attention. The other options are incorrect because: A: Suspicious of others is more characteristic of paranoid personality disorder. B: Callousness is more indicative of antisocial personality disorder. D: Violates others' rights is a feature of antisocial personality disorder as well.