Nokea
A nurse is preparing a client's intravenous (IV) infusion. As the nurse was preparing to attach the distal end of the IV tubing to the client's needleless access device, the exposed tubing slipped and hit the top of the client's bedside table. Which of the following is the most appropriate action by the nurse?
- A. Replace the IV tubing with new tubing
- B. Discard the client's current needleless access device and replace it with a new one
- C. Wipe the distal end of the tubing with povidone-iodine to render it sterile
- D. Clean the needleless access device with an alcohol swab
Correct Answer: A
Rationale: Replacing the tubing ensures sterility after contact with a non-sterile surface.
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The nurse is caring for a client two days post-operative following gastroduodenostomy. After reviewing the clinical data, the nurse should take which action?
- A. obtain a prescription for an antihypertensive
- B. determine if the client's pain is being controlled
- C. assess the client's surgical wound for signs of infection
- D. notify the physician for concerns of hypovolemic shock
Correct Answer: D
Rationale: Without specific clinical data, the priority for a client two days post-gastroduodenostomy is to assess for hypovolemic shock, a potential complication due to bleeding or fluid loss from the surgical site. This is more urgent than pain control, wound infection assessment, or antihypertensive needs, which require specific clinical indicators.
The nurse is caring for a client with pulmonary tuberculosis. Which action should the nurse take?
- A. Place a box of disposable respirators inside the client's room.
- B. Remove alcohol-based sanitizers from the client's room.
- C. Assign the client to a private room with a positive airflow.
- D. Remove the portable fan from the client's bedside table.
Correct Answer: D
Rationale: Removing the portable fan prevents the spread of airborne Mycobacterium tuberculosis. A negative airflow room is required, and respirators should be stored outside the room.
The nurse is assigned to multiple clients with fever. Taking a rectal temperature would be contraindicated in which of the following cases? Select all that apply.
- A. A client who had rectal surgery and a post-operative abscess
- B. A child who has pneumonia
- C. An older client who is post-myocardial infarction (MI)
- D. A teenager with leukemia, a neutrophil count of 500/microliter, and is receiving erythropoietin for anemia
- E. An adult patient with acute pancreatitis and has disseminated intravascular coagulation (DIC)
Correct Answer: A,D,E
Rationale: Rectal temperature is contraindicated in rectal surgery/abscess (due to trauma risk), neutropenia (infection risk), and DIC (bleeding risk). Pneumonia and post-MI do not contraindicate rectal measurement.
The nurse is caring for a client who has severe burns on their right arm and is in pain despite receiving a prescribed pain medication. The nurse decides to rub the client's uninjured left arm to relieve pain in the right. This approach is called
- A. Biofeedback.
- B. Contralateral stimulation.
- C. Transcutaneous electrical nerve stimulator (TENS).
- D. Acupressure.
Correct Answer: B
Rationale: Contralateral stimulation involves stimulating the opposite side to reduce pain perception, effective for some pain types. Biofeedback, TENS, and acupressure are different modalities.
One of the complications associated with the improper use of crutches is:
- A. Axillary nerve damage
- B. Solar plexus nerve damage
- C. Carpal tunnel syndrome
- D. Trigeminal nerve damage
Correct Answer: A
Rationale: Improper crutch use can compress the axillary nerve, causing nerve damage. Other options are unrelated to crutches.