Nokea
A nurse is caring for a client who has complete immobility and is bedbound. Which of the following complications should the nurse monitor for? Select all that apply.
- A. Peripheral neuropathy
- B. Increased peristalsis leading to diarrhea
- C. Joint contractures
- D. Increased bone density
- E. Peripheral edema
- F. Pneumonia
Correct Answer: C,E,F
Rationale: Immobility causes contractures, edema, and pneumonia due to reduced mobility and lung expansion. Neuropathy and increased peristalsis are unrelated, and bone density decreases.
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The nurse in the postanesthesia care unit (PACU) cares for a client who had an appendectomy. Which of the following client assessments warrants immediate follow-up?
- A. has breath sounds that are high-pitched and crowing
- B. reports incisional pain at a level of '5' on a scale of 0 (no pain) to 10 (severe pain)
- C. has a capillary blood glucose of 115 mg/dL [70-110 mg/dL]
- D. reports persistent nausea following the administration of an anti-emetic
Correct Answer: A
Rationale: High-pitched, crowing breath sounds suggest airway obstruction or stridor, a critical finding requiring immediate intervention to ensure airway patency. Moderate pain, slightly elevated glucose, and nausea are less urgent.
The nurse is preparing to obtain capillary blood glucose (CBG) for a client with diabetes mellitus. The nurse should take which action? Select all that apply.
- A. Apply gloves for this procedure
- B. Have the client wash their hands with soap and water prior to blood collection
- C. Collect the second blood drop on the test strip
- D. Prick the central part of the finger for the sample
- E. Clean and disinfect the glucometer in between uses
Correct Answer: A,B,C,E
Rationale: Gloves protect against blood exposure, hand washing ensures a clean sample, the second drop avoids contamination, and disinfecting the glucometer prevents infection. Pricking the central finger part is less preferred than the side.
The nurse supervises unlicensed assistive personnel (UAP) assist a bed-bound client with oral hygiene. Which action by the UAP requires follow-up? Select all that apply.
- A. Raises the head of the bed (HOB) to 15 degrees
- B. Positions the toothbrush bristles at a 45-degree angle to the gum line
- C. A pulse of 5 is abnormally low for a 5-year-old (normal 70-120). BP 110/60, RR 24, and temperature 37°C are within normal limits. None Regular The correct answer is A. Rationale: Pulse 5 is bradycardic for a child.
- D. Removes the towel and places it in a biohazard bag
- E. Applies moisturizing lubricant to the lips after brushing and rinsing
Correct Answer: A,D
Rationale: These actions by the UAP require follow-up. The head of the bed should ideally be elevated to between 30-45 degrees to facilitate effective oral hygiene and reduce the risk of aspiration. A lower angle may make it more difficult for the client to swallow properly and increase the risk of choking. Placing a towel used for oral hygiene in a biohazard bag is unnecessary unless it is saturated with blood or other potentially infectious materials. The towel used to protect the client's clothing during oral hygiene is typically considered regular linen and should be placed in a linen bag for laundering. Using a biohazard bag for non-contaminated items increases waste and may lead to confusion in waste management procedures.
The nurse is supervising a graduate nurse completing an incident report regarding a client who fell. Which of the following actions by the graduate nurse requires follow-up?
- A. Documents an objective description of what happened
- B. Indicates that a 2-inch laceration was present on the client's scalp
- C. Documents in the nursing note that an incident report was completed
- D. Indicates the follow-up actions taken
Correct Answer: C
Rationale: Documenting the incident report in the nursing note violates confidentiality; incident reports are separate from patient records.
The nurse is presenting a home safety class on carbon monoxide toxicity to a group of older adults. Which statement would be appropriate for the nurse to make to the group of clients?
- A. Carbon monoxide is a gas that is gray in color and deadly.
- B. Carbon monoxide is a clear and odorless gas.
- C. Early signs of carbon monoxide toxicity include nose bleed and tremors.
- D. Carbon monoxide is a gas that smells like rotten eggs.
Correct Answer: B
Rationale: Carbon monoxide is a colorless, odorless gas, making detectors essential. It is not gray, does not smell like rotten eggs, and early signs include headache, not nosebleeds or tremors.