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A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position their hands?
- A. Place one hand over the other against the part of the gown covering their upper body.
- B. Clasp their hands together in a relaxed position behind their body at their waist.
- C. Keep their arms at the sides of their body with their hands in a relaxed position.
- D. Interlock their fingers and hold their hands away from their body above their waist.
Correct Answer: D
Rationale: Interlocking fingers above the waist prevents contamination of sterile gloves.
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A nurse is assisting in the care of a client who has pneumonia in the medical unit. Which of the following information should the nurse include in discharge teaching for the client? (Select all that apply)
- A. Take antibiotics for 10 days.
- B. Ensure the oxygen delivery system is at least 8 feet from any heat source.
- C. Decrease the steroid dose each day.
- D. Take antibiotic medication with or without food.
- E. Adjust the oxygen flow rate as needed to ease breathing.
- F. Take steroid medication in the morning.
Correct Answer: A,B,D,F
Rationale: A: Ensures full treatment course. B: Reduces fire hazard. D: Flexibility aids compliance. F: Morning dosing minimizes sleep disruption.
A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?
- A. Check the client's medical records to see which medications were recently administered.
- B. Review the client's most recent SaO2 level in the medical record.
- C. Notify the charge nurse of the client's condition.
- D. Recheck the client's SaO2 level after having the client cough and clear their throat.
Correct Answer: D
Rationale: Rechecking after coughing assesses if the low SaO2 is due to mucus, addressing it immediately.
A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?
- A. Place the client's arms above her head prior to logrolling.
- B. Place the client in semi-Fowler's position prior to logrolling.
- C. Place the bed in the lowest position before logrolling the client.
- D. Place a pillow between the client's legs prior to logrolling.
Correct Answer: D
Rationale: A pillow maintains spinal alignment during logrolling post-laminectomy.
A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, 'I miss being able to go places with my friends.' Which of the following is an appropriate response by the nurse?
- A. We can discuss this when you're not feeling overwhelmed.
- B. Have you tried taking your partner with you when you go out?
- C. Tell me more about your expectations.
- D. I understand how you feel. I've had a relative go through the same thing.
Correct Answer: C
Rationale: Asking about expectations opens dialogue and shows empathy, supporting the partner's needs.
A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which sequence should the nurse perform the following steps?
- A. Apply clean gloves.
- B. Disconnect the tube from the suction device.
- C. Instill 50 mL of air into the tube.
- D. Ask the client to take a deep breath.
- E. Pinch and withdraw the tube.
Correct Answer: A,B,C,D,E
Rationale: A: Gloves ensure hygiene. B: Disconnect suction. C: Air clears tube. D: Breath aids removal. E: Pinch prevents leakage.