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A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following hip replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Place a throw rug over electrical cords
- C. Mark the edges of the doorway to the house with tape.
- D. Ensure that area rugs have rubber backs.
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction helps prevent slipping and falling, which is crucial for a postoperative hip replacement patient. Rubber-backed rugs provide stability and reduce the risk of accidents. Option A is incorrect as wearing shoes at home can increase the risk of falls. Option B is incorrect as placing a throw rug over electrical cords can lead to tripping hazards. Option C is incorrect as marking doorways with tape does not address home safety concerns for a postoperative patient.
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A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take?
- A. Discard the radioactive source in the client's trash can.
- B. Place the client's soiled bed linens in a biohazard bag outside the client's room
- C. Wear an isolation gown when caring for the client
- D. Keep visitors at least 6 feet (1.8 m) away from the client.
Correct Answer: D
Rationale: The correct answer is D: Keep visitors at least 6 feet (1.8 m) away from the client. This is important in brachytherapy as the client is emitting radiation. By keeping visitors at a safe distance, the nurse ensures their safety from radiation exposure. A: Discarding the radioactive source in the trash can is incorrect as it poses a risk to others. B: Placing soiled linens in a biohazard bag is not directly related to radiation safety. C: Wearing an isolation gown does not provide sufficient protection against radiation. Therefore, it is important for the nurse to maintain distance to prevent radiation exposure to visitors.
The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process
- A. Hemoglobin
- B. Alanine aminotransferase (ALT)
- C. Blood pressure
- D. Platelet count
Correct Answer: C: Preeclampsia; A, B, D: HELLP
Rationale: The correct answer is: C: Preeclampsia; A, B, D: HELLP.
1. Blood pressure is consistent with preeclampsia as elevated blood pressure is a key characteristic.
2. Hemoglobin, Alanine aminotransferase (ALT), and Platelet count are consistent with HELLP syndrome, as these markers are commonly affected in this condition.
3. Preeclampsia is characterized by hypertension and proteinuria, while HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelet count.
4. Therefore, based on the assessment findings provided, elevated blood pressure aligns with preeclampsia, while abnormalities in hemoglobin, ALT, and platelet count suggest HELLP syndrome.
A nurse is caring for a client whose child died from cancer. The client states, 'It's hard to go on without him.' Which of the following questions should the nurse ask the client first?
- A. What has helped you through difficult times in the past?'
- B. Has anyone in your family committed suicide?'
- C. Is there anyone you would like involved in your care?'
- D. Are you thinking about ending your life?'
Correct Answer: D
Rationale: The correct question to ask first is D: "Are you thinking about ending your life?" This is important to assess the client's risk of suicide, as the statement "It's hard to go on without him" can indicate suicidal ideation. It is crucial to address safety concerns immediately. Asking about coping strategies (A) can come later. Inquiring about family suicide history (B) may not be relevant at this stage. Involving others in care (C) is important but not as urgent as assessing suicidal thoughts.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the swelling of the epiglottis can rapidly obstruct the airway, leading to respiratory distress or failure. Intubation is crucial to secure the airway and ensure adequate oxygenation. Obtaining a throat culture (B) may delay necessary intervention. Suctioning the oropharynx (C) can trigger spasm and worsen the obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.
A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?
- A. I will hang a new bag of TPN and IV tubing every 24 hours.'
- B. I will obtain the client's weight every other day.'
- C. I will monitor the client's blood glucose level every 8 hours.'
- D. I will increase the rate of the TPN infusion to ensure the correct amount is given.'
Correct Answer: A
Rationale: Correct Answer: A - "I will hang a new bag of TPN and IV tubing every 24 hours."
Rationale: Changing the TPN bag and tubing every 24 hours is crucial to prevent contamination and infection. TPN is a high-risk solution that can support bacterial growth. Changing the bag and tubing decreases the risk of infection and ensures the client receives fresh and uncontaminated TPN.
Summary of Incorrect Choices:
B: Obtaining the client's weight every other day is important for adjusting the TPN formula but does not demonstrate an understanding of the procedure like changing the bag and tubing.
C: Monitoring the client's blood glucose level every 8 hours is important for assessing tolerance to TPN but does not directly relate to the procedural aspect of TPN administration.
D: Increasing the rate of TPN infusion to ensure the correct amount is given is not safe practice and can lead to complications. The rate should be prescribed by the healthcare provider and not arbitrarily increased.