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A nurse is obtaining an oxygen saturation on a client. Which of the following actions should the nurse take?
- A. Wait 10 sec after placing the probe before obtaining the oxygen saturation reading
- B. Place the sensor probe on the same extremity as an electronic blood pressure cuff
- C. Relocate the sensor every 8 hrs
- D. Choose a finger with a capillary refill less than 2 sec
Correct Answer: D
Rationale: The correct answer is D: Choose a finger with a capillary refill less than 2 sec. This is important because a capillary refill time longer than 2 seconds may indicate poor circulation, which can affect the accuracy of the oxygen saturation reading. It ensures proper blood flow to the finger, leading to a more reliable measurement. Waiting 10 seconds before obtaining the reading (A) is unnecessary and may delay timely intervention. Placing the sensor probe on the same extremity as an electronic blood pressure cuff (B) can interfere with accurate readings. Relocating the sensor every 8 hours (C) is not necessary for routine monitoring and may disrupt continuous monitoring.
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A nurse is assessing a client who has circulatory overload. Which of the following findings should the nurse expect?
- A. Diaphoresis
- B. Weight loss
- C. Hypotension
- D. Tachycardia
Correct Answer: D
Rationale: The correct answer is D: Tachycardia. In circulatory overload, the body is trying to compensate for the increased volume of fluid in the circulatory system by increasing the heart rate to maintain adequate circulation. Diaphoresis (A) is excessive sweating, not typically associated with circulatory overload. Weight loss (B) is not expected as circulatory overload is characterized by excess fluid retention. Hypotension (C) is unlikely as the body's response to fluid overload is to increase blood pressure. Tachycardia (D) is the correct choice as the heart rate increases to help pump the excess fluid throughout the body.
A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
- A. Prepares the sterile field 2 hr before it is needed
- B. Uses a surface that is at waist height
- C. Places the sterile field against a wall in the client's room
- D. Opens the first flap of the sterile package towards the nurse's body
Correct Answer: B
Rationale: The correct answer is B because setting up a sterile field at waist height minimizes the risk of contamination. This position ensures better visibility and accessibility for the nurse while maintaining sterility. Choice A is incorrect as preparing the sterile field too early can lead to contamination. Choice C is incorrect as placing the sterile field against a wall increases the risk of contamination from the wall. Choice D is incorrect because the first flap should be opened away from the body to prevent contamination.
A nurse on a medical unit is reviewing the laboratory reports for a client. Which of the following laboratory values is the priority to report to the provider?
- A. Potassium level 3 mEq/L
- B. BUN 9.5 mg/dL
- C. Creatinine 0.4 mg/dL
- D. Sodium 135 mEq/L
Correct Answer: A
Rationale: The correct answer is A: Potassium level 3 mEq/L. A potassium level of 3 mEq/L is below the normal range (3.5-5.0 mEq/L), indicating hypokalemia. Hypokalemia can lead to serious cardiac arrhythmias. Therefore, it is crucial to report this abnormal potassium level promptly to the provider for further evaluation and intervention.
B: BUN 9.5 mg/dL - This is within the normal range (7-20 mg/dL) and does not require immediate intervention.
C: Creatinine 0.4 mg/dL - This is within the normal range (0.6-1.2 mg/dL) and does not indicate an urgent issue.
D: Sodium 135 mEq/L - This is within the normal range (135-145 mEq/L) and does not require immediate action.
A nurse is gathering evidence-based practice on catheter-associated urinary tract infections (CAUTI). Which of the following roles is the nurse performing?
- A. Researcher
- B. Nurse manager
- C. Case manager
- D. Educator
Correct Answer: A
Rationale: The correct answer is A: Researcher. The nurse is gathering evidence-based practice on CAUTI, which involves conducting research to gather relevant information, analyze data, and draw conclusions based on evidence. This role aligns with the responsibilities of a researcher who systematically investigates a topic to contribute to the body of knowledge. The other choices are incorrect because: B: Nurse managers oversee nursing staff and operations, C: Case managers coordinate patient care, and D: Educators focus on teaching and disseminating knowledge. In this scenario, the nurse's primary role is to gather evidence through research, making option A the most appropriate choice.
A nurse opens a unit-dose of a prescribed medication prior to administering it to a client. After education, the client refuses to take the medication. Which of the following actions should the nurse take?
- A. Notify the facility’s ethics committee
- B. Return the opened medication to the medication cart
- C. Report the incident to the provider
- D. Fill out an incident report
Correct Answer: C
Rationale: The correct answer is C: Report the incident to the provider. The nurse should report the client's refusal to take the medication to the provider to ensure appropriate documentation and follow-up care. This step is crucial for the client's safety and well-being.
A: Notifying the ethics committee is not necessary in this situation as the provider should be the first point of contact.
B: Returning the opened medication to the cart is inappropriate and unsafe as it could lead to medication errors.
D: Filling out an incident report may be necessary, but reporting to the provider should be the immediate action.
In summary, option C is the correct choice as it prioritizes the client's care and ensures proper communication with the healthcare provider.