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A nurse is reviewing the medical history of a client who is listed for surgery. Which of the following findings places the client at risk for a complication of incisional hematoma forming?
- A. The client is underweight
- B. The client takes anticoagulant medications
- C. The client has urinary incontinence
- D. The client has peripheral vascular disease
Correct Answer: B
Rationale: The correct answer is B: The client takes anticoagulant medications. Anticoagulant medications inhibit blood clotting, increasing the risk of bleeding and hematoma formation at the surgical site. This poses a significant complication during and after surgery. Other choices are incorrect because being underweight (A), having urinary incontinence (C), and having peripheral vascular disease (D) do not directly increase the risk of incisional hematoma formation.
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A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall? Select all that apply.
- A. Electrical cord on floor over a walkway
- B. Demonstrates correct use of cane to ambulate
- C. Grab bar in the bathroom
- D. Diagnosis of macular degeneration
- E. Throw rugs in kitchen
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
- A: An electrical cord on the floor is a tripping hazard, increasing the risk of falls.
- D: Macular degeneration affects vision, leading to difficulties in depth perception and obstacle detection, increasing fall risk.
- E: Throw rugs in the kitchen can cause slipping or tripping, posing a fall hazard.
Summary of Incorrect Choices:
- B: Demonstrating correct use of a cane indicates the client is taking precautions to prevent falls.
- C: Having a grab bar in the bathroom is a safety measure to prevent falls.
- F and G: Not provided in the question, so cannot be evaluated.
A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?
- A. The client who has a nasogastric (NG) tube to suction
- B. The client who has a chest tube to water seal
- C. The client who has an indwelling urinary catheter to gravity drainage
- D. The client who has a tracheostomy tube attached to humidified oxygen
Correct Answer: A
Rationale: The correct answer is A: The client who has a nasogastric (NG) tube to suction. Suctioning through the NG tube can lead to loss of gastric contents, including potassium, which can result in hypokalemia. The other choices do not directly affect potassium levels. B: A chest tube to water seal is used to drain air or fluid from the pleural space, not likely to cause hypokalemia. C: An indwelling urinary catheter to gravity drainage does not impact potassium levels. D: A tracheostomy tube with humidified oxygen does not affect potassium levels. Therefore, the client with the NG tube to suction is at risk for hypokalemia due to potential potassium loss.
A nurse is teaching a newly licensed nurse about preventing puncture injuries. Which of the following instructions should the nurse include?
- A. Break needles on syringes before disposal
- B. Use two hands to recap a needle after administering a medication
- C. Dispose of used razors in wastebaskets
- D. Replace sharps containers when they are 3/4 full
Correct Answer: D
Rationale: The correct answer is D: Replace sharps containers when they are 3/4 full. This instruction is crucial in preventing puncture injuries as overfilling sharps containers can increase the risk of accidental needle sticks. By replacing the containers when they are 3/4 full, it ensures that there is enough space to safely dispose of needles and other sharp objects without risking spills or injuries.
Explanation of other choices:
A: Breaking needles on syringes before disposal is unsafe as it can increase the risk of needle stick injuries.
B: Using two hands to recap a needle is dangerous and not recommended as it can lead to accidental needle sticks.
C: Disposing of used razors in wastebaskets is improper as they should be disposed of in puncture-proof containers.
Summary: Option D is the correct choice as it emphasizes safe disposal practices to prevent puncture injuries, while the other options promote unsafe practices that can increase the risk of needle stick injuries.
The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers. Which lab value would the nurse expect to see?
- A. Chloride 112
- B. Calcium 7.5
- C. Potassium 4.0
- D. Calcium 12.1
Correct Answer: B
Rationale: The correct answer is B: Calcium 7.5. With partial removal of the parathyroid gland, there may be decreased production of parathyroid hormone leading to hypocalcemia. Numbness and tingling in the hands and fingers are classic symptoms of hypocalcemia. A low calcium level of 7.5 is indicative of this condition.
Choice A: Chloride 112 is not related to symptoms of numbness and tingling.
Choice C: Potassium 4.0 is within the normal range and not associated with symptoms of hypocalcemia.
Choice D: Calcium 12.1 indicates hypercalcemia, not hypocalcemia, which would not cause numbness and tingling.
A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Teach the use of an incentive spirometer to a postoperative client
- B. Irrigate and perform a dressing change for a client who has a pressure injury wound
- C. Administer oral PRN pain medication to a client who has arthritis
- D. Obtain a daily weight on a client who has heart failure
Correct Answer: D
Rationale: The correct answer is D: Obtain a daily weight on a client who has heart failure. The rationale is as follows: Delegating the task of obtaining a daily weight to an assistive personnel (AP) is appropriate because it is a routine, non-invasive task that does not require specialized knowledge or skills. Daily weight monitoring is crucial for clients with heart failure to assess for fluid retention or loss, which is essential for managing the condition effectively. APs are trained to perform basic tasks like measuring weight and can report any significant changes to the nurse for further evaluation.
Summary of why the other choices are incorrect:
A: Teaching the use of an incentive spirometer requires specialized knowledge and skill that only a nurse should perform.
B: Irrigating and performing a dressing change for a pressure injury wound requires sterile technique and assessment skills that are beyond the scope of an AP.
C: Administering PRN pain medication involves assessing the client's condition, pain level, and potential side effects,