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A nurse is taking care of a client undergoing cerebral angiography. Which statement by the client would require immediate follow-up?
- A. I feel like I'm going to vomit.
- B. I hope my results are okay.
- C. It's getting a bit hot in here.
- D. My throat is getting a bit itchy, and my eyes are getting watery.
Correct Answer: D
Rationale: Itchy throat and watery eyes suggest an allergic reaction to the contrast dye, requiring immediate intervention. Nausea, hopefulness, and feeling warm are less urgent.
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The nurse is participating in a committee changing the hospital security plan. Which of the following statements by the nurse would be appropriate to make? Select all that apply.
- A. Open visitation should be implemented in the newborn nursery.
- B. Visitors should always wear a badge while in the hospital
- C. Oral temperatures should be obtained for all visitors
- D. Hand sanitizing stations should be offered throughout the facility
- E. Disaster drills should be conducted to ensure staff competency
Correct Answer: B,D,E
Rationale: Visitor badges, hand sanitizing stations, and disaster drills enhance security. Open visitation in nurseries and visitor temperature checks are impractical or unsafe.
Which of the following must NOT be included in an incident or accident form or report?
- A. The name of the person completing the report.
- B. The name of the client and if anyone was injured.
- C. The location of the incident or accident.
- D. An explanation of what may have led to the incident.
Correct Answer: NONE
Rationale: All listed elements are typically required in an incident report to ensure accurate documentation and follow-up.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 6 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each assessment finding, click to specify if the finding indicates that the client's condition has improved, not changed, or worsened.
- A. Toileting access
- B. Medication organization
- C. Urinary patterns
- D. Activity tolerance
- E. Lower extremities
- F. Bathroom lighting
Correct Answer: A,B,C:Improved;D,E,F:Unchanged
Rationale: Improved toileting access, medication organization, and urinary patterns indicate better management. Activity tolerance, lower extremity symptoms, and bathroom lighting remain unchanged.
The nurse has attended a continuing education program about infection control precautions. It would indicate a correct understanding of the teaching if the nurse is observed
- A. wearing gloves when obtaining vital signs.
- B. cohorting two clients with influenza in the same room.
- C. wearing a surgical mask when caring for a client with suspected rabies.
- D. initiating droplet precautions for a client with viral pneumonia.
Correct Answer: B,D
Rationale: Cohorting influenza clients and initiating droplet precautions for viral pneumonia align with infection control guidelines. Gloves for vital signs and a mask for rabies are not standard.
The nurse is caring for a client who is immediately postoperative following a colon resection with the placement of a colostomy. Which of the following client problems are of greatest concern?
- A. Infection
- B. Thermoregulation
- C. Hemorrhage
- D. Altered body image
Correct Answer: C
Rationale: Hemorrhage is the greatest concern immediately post-colon resection due to the risk of significant blood loss from the surgical site, which can be life-threatening. Infection, thermoregulation, and altered body image are important but less immediate.