Nokea
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?
- A. Carefully remove the gloves and follow with hand hygiene
- B. Continue with the procedure and clean hands later
- C. Remove the gloves, wash hands, and start over
- D. Use hand sanitizer and continue the procedure
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to carefully remove the gloves and follow with hand hygiene. This is important to prevent potential contamination and maintain infection control practices. Option B is incorrect because cleaning hands later may lead to the spread of potential contaminants. Option C is unnecessary as starting over is not required if proper hand hygiene is performed. Option D is not sufficient in ensuring proper hygiene after a blood spill, as hand sanitizer may not effectively remove all contaminants.
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A client with a history of hypertension is prescribed a diuretic. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the medication?
- A. Monitor serum calcium levels.
- B. Monitor serum potassium levels.
- C. Monitor serum sodium levels.
- D. Monitor serum magnesium levels.
Correct Answer: B
Rationale: The correct answer is to monitor serum potassium levels. When a client is prescribed a diuretic, monitoring serum potassium levels is essential to evaluate the medication's effectiveness and to detect potential electrolyte imbalances. Diuretics can cause potassium loss, leading to hypokalemia, which can have serious consequences such as cardiac arrhythmias. Monitoring serum calcium levels (Choice A) is not typically required when assessing the effectiveness of diuretics. Similarly, monitoring serum sodium levels (Choice C) is important for other conditions but is not the primary concern when evaluating diuretic therapy. Monitoring serum magnesium levels (Choice D) is also important, but potassium levels are more critical in assessing diuretic effectiveness and preventing complications.
A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests that the client has postherpetic neuralgia?
- A. Linear clusters of vesicles on the right shoulder.
- B. Purulent drainage from both eyes.
- C. Decreased white blood cell count.
- D. Report of continued pain following resolution of the rash.
Correct Answer: D
Rationale: The correct answer is D: Report of continued pain following resolution of the rash. Postherpetic neuralgia is a complication of herpes zoster characterized by persistent pain that continues even after the rash has resolved. This pain can be severe and debilitating, affecting the quality of life of the individual. Choices A, B, and C are incorrect because linear clusters of vesicles on the right shoulder would suggest an active herpes zoster outbreak, purulent drainage from both eyes would indicate an eye infection unrelated to postherpetic neuralgia, and a decreased white blood cell count is not typically associated with postherpetic neuralgia.
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the LPN/LVN include in this client's teaching plan?
- A. You will be able to bend at the waist to reach items on the floor in 8 weeks.
- B. Place a pillow between your knees while lying in bed to prevent hip dislocation.
- C. It is safe to use a walker to get out of bed, but you need assistance when walking.
- D. Take pain medication 30 minutes after your physical therapy sessions.
Correct Answer: B
Rationale: The correct instruction to include in the teaching plan for a client who had a hemiarthroplasty of the left hip is to 'Place a pillow between your knees while lying in bed to prevent hip dislocation.' This technique helps maintain proper hip alignment and prevents dislocation during the postoperative recovery period. Choice A is incorrect because bending at the waist to reach items on the floor can strain the hip joint and is not recommended following hip surgery. Choice C is incorrect because using a walker alone without assistance can increase the risk of falls and injury, especially in the immediate postoperative period. Choice D is incorrect because pain medication should be taken as prescribed by the healthcare provider, not specifically timed after physical therapy sessions.
A client with a terminal illness is being educated by a healthcare provider about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the ED and I had difficulty breathing?"
- A. We would give you oxygen through a tube in your nose.
- B. We would initiate full resuscitation efforts.
- C. We would consult the living will and provide comfort care.
- D. We would not provide any medical intervention.
Correct Answer: C
Rationale: In the scenario described, the client has a living will that declines resuscitation. Therefore, if the client arrives at the emergency department with difficulty breathing, healthcare providers would consult the living will to understand the client's wishes. Providing comfort care, which may include oxygen therapy to alleviate symptoms, aligns with the client's preferences. Option A incorrectly suggests an intervention that goes against the client's wishes. Option B is incorrect because full resuscitation efforts are not in line with the client's choice to decline resuscitation. Option D is also incorrect as it does not consider the client's living will and the need to provide care according to the documented preferences of the client.
How should a healthcare professional care for a client approaching death with shortness of breath and noisy respirations?
- A. Turn the client every 2 hours
- B. Provide supplemental oxygen
- C. Use a fan to reduce the feeling of breathlessness
- D. Administer diuretics as prescribed
Correct Answer: C
Rationale: In a palliative care setting, when caring for a client approaching death with symptoms of shortness of breath and noisy respirations, using a fan can help alleviate the sensation of breathlessness. This intervention can provide comfort by improving air circulation and reducing the perception of breathlessness. Turning the client every 2 hours may not directly address the respiratory distress caused by noisy respirations. Providing supplemental oxygen may not be indicated or effective in all cases, especially in end-of-life care where the focus is on comfort rather than aggressive interventions. Administering diuretics as prescribed would not be appropriate for addressing noisy respirations and shortness of breath in a dying client, as this may not be related to fluid overload or congestion. Therefore, the most appropriate action to help the client feel more comfortable in this situation is to use a fan to reduce the feeling of breathlessness.