Nokea
A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?
- A. Assign different nurses to provide care for clients each day.
- B. Restrict the number of visitors for clients.
- C. Offer the clients many choices regarding care.
- D. Turn on loud music in client care areas.
Correct Answer: B
Rationale: Restricting visitors reduces noise and stress in an acute care setting.
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A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
- B. Unlock and remove the inner cannula.
- C. Scrub the inside and outside of the inner cannula with a small brush.
- D. Cleanse the stoma site with 0.9% sodium chloride solution.
- E. Wipe the inside of the inner cannula with a folded pipe cleaner.
Correct Answer: A,B,C,E,D
Rationale: A: Prepare solution. B: Remove cannula. C: Scrub cannula. E: Wipe cannula. D: Cleanse stoma ensures sterile technique.
A nurse is planning to obtain a client's oxygen saturation. Which of the following might influence the result of this test?
- A. The client has a fever.
- B. The client has an elevated hemoglobin level.
- C. The client is wearing a ring.
- D. The client is wearing nail polish.
Correct Answer: D
Rationale: Nail polish can interfere with pulse oximetry readings by absorbing light.
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps?
- A. Unlock and remove the inner cannula.
- B. Scrub the inside and outside of the inner cannula with a small brush
- C. Wipe the inside of the inner cannula with a folded pipe cleaner.
- D. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
- E. Cleanse the stoma site with 0.9% sodium chloride solution.
Correct Answer: A, D, B, C, E
Rationale: Sequence ensures sterile preparation and cleaning: remove cannula, prepare solution, scrub, wipe, cleanse stoma.
A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?
- A. Not receiving blood will slow down your recovery.
- B. I understand that you decided not to receive blood products.
- C. You need to talk with your doctor about this.
- D. Why are you refusing to receive blood products?
Correct Answer: B
Rationale: Acknowledging the client's decision respects their autonomy and opens a dialogue.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many ml should the nurse administer with each dose?
- A. 12.5 mL (calculated: 55 lb = 25 kg, 50 mg/kg = 1250 mg/day, 1250 mg / 4 doses = 312.5 mg/dose, 312.5 mg / 125 mg/5 mL = 12.5 mL)
Correct Answer: A
Rationale: Calculation confirms 12.5 mL per dose is correct.