Nokea
A nurse is assisting in the care of a client who is receiving newly prescribed IV antibiotics. Which of the following findings should the nurse report immediately?
- A. Small, raised vesicles over the body
- B. Rhinitis
- C. Itching of the skin
- D. Severe wheezing
Correct Answer: D
Rationale: Severe wheezing indicates a possible anaphylactic reaction, requiring immediate reporting.
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A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Cleanse the wound with cotton balls.
- B. Use a 10-mL syringe filled with cleansing solution.
- C. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
- D. Dry the wound bed with gauze squares.
Correct Answer: C
Rationale: This technique ensures effective irrigation without damaging tissue.
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)
- A. A client reports being dissatisfied with the temperature of the meals provided.
- B. A client receives burns from a heating pad.
- C. A client becomes disoriented and falls out of bed.
- D. A client is unable to afford the physical therapy that the provider recommends.
- E. A client's visitor becomes dizzy and faints in the client's room.
Correct Answer: B,C,E
Rationale: B: Burns indicate harm. C: Falls require reporting. E: Visitor fainting is an unexpected event.
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Squeeze the client's finger until a blood drop forms
- B. Prick the side of the client's finger.
- C. Elevate the client's hand above the level of the heart
- D. Cleanse the client's finger with an iodine swab
- E. Using clean gloves
Correct Answer: B, E
Rationale: B: Pricking the side avoids painful areas. E: Clean gloves ensure infection control.
A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Administer prescribed diuretics in the evening.
- B. Use overhead lighting when checking equipment.
- C. Keep the door to the client's room closed.
- D. Provide the client with snug-fitting nightwear.
Correct Answer: C
Rationale: A closed door reduces noise, promoting sleep.
A nurse is checking for proper placement of a feeding tube. Which of the following methods is the most reliable for verification of tube placement?
- A. Verify the bilirubin level of the tube contents.
- B. Auscultate for air insufflation.
- C. Request a chest x-ray.
- D. Check the pH level of gastric contents.
Correct Answer: C
Rationale: A chest x-ray is the gold standard for confirming feeding tube placement.