Nokea
A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members?
- A. Charge nurse
- B. Registered nurse (RN)
- C. Practical nurse (PN)
- D. Assistive personnel (AP)
Correct Answer: B
Rationale: In this scenario, a client who has undergone thoracic surgery and is being admitted from the PACU requires a high level of nursing care. Registered nurses (RNs) have the education and training necessary to provide the complex care and monitoring needed for a post-thoracic surgery client. Charge nurses may oversee units but may not always be directly involved in providing bedside care. Practical nurses (PNs) have a different scope of practice compared to RNs and may not have the advanced skills needed for post-thoracic surgery care. Assistive personnel (AP) provide valuable support but do not have the qualifications to manage the care of a client following thoracic surgery.
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An older adult client appears agitated when the nurse requests that the client's dentures be removed prior to surgery and states, "I never go anywhere without my teeth." Which of the following is an appropriate nursing response?
- A. You should comply with the request
- B. You seem worried. Are you concerned someone may see you without your teeth?
- C. I will call your family to discuss this
- D. It's not a big deal; just remove them
Correct Answer: B
Rationale: The appropriate nursing response in this situation is to acknowledge and address the client's concerns empathetically. By expressing understanding and asking if the client is worried about being seen without their teeth, the nurse shows empathy and attempts to alleviate the client's anxiety. Choice A is incorrect as it dismisses the client's feelings. Choice C is inappropriate as it does not directly address the client's agitation. Choice D is not the best response as it minimizes the client's feelings and does not provide emotional support.
A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?
- A. The nurse washes with her hands held higher than her elbows.
- B. The nurse uses an alcohol-based hand rub for 30 seconds.
- C. The nurse scrubs hands and forearms for 2 minutes with soap and water.
- D. The nurse washes her hands with soap and water for only 15 seconds.
Correct Answer: A
Rationale: Proper surgical hand-washing technique involves washing with the hands held higher than the elbows. This positioning is essential to ensure proper rinsing and to prevent the risk of contamination. Option B, using an alcohol-based hand rub for 30 seconds, is not specific to surgical hand-washing and is more commonly used for routine hand hygiene. Option C, scrubbing hands and forearms for 2 minutes with soap and water, is excessive and not typically required for routine hand-washing. Option D, washing hands with soap and water for only 15 seconds, is insufficient for thorough surgical hand-washing.
A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
- A. Why don¢â‚¬â„¢t we now have the client turn back to the left side.
- B. That was done correctly. Did you have any problems with the insertion?
- C. Let¢â‚¬â„¢s check to see if the suppository is in far enough.
- D. Did you feel any stool in the intestinal tract?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Pad the client's wrists before applying the restraints
- B. Tie the restraints to the side rails of the bed
- C. Secure the restraints to the bed frame
- D. Use a quick-release knot to tie the restraints
Correct Answer: A
Rationale: The correct action for the nurse to take when a client has a new prescription for wrist restraints is to pad the client's wrists before applying the restraints. This is important to prevent skin breakdown and injury. Tying the restraints to the side rails of the bed (Choice B) is unsafe and can lead to potential harm for the client. Similarly, securing the restraints to the bed frame (Choice C) is not appropriate as it can restrict the client's movement and cause discomfort. Using a quick-release knot to tie the restraints (Choice D) is also incorrect as it may compromise the effectiveness of the restraints in ensuring client safety.
During an IV catheter insertion demonstration, which statement by a nurse indicates understanding of the procedure?
- A. "I will thread the needle into the vein at an angle of 10 to 30 degrees with the bevel up."
- B. "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up."
- C. "I will apply pressure approximately 1.2 inches below the insertion site before removing the needle."
- D. "I will select a vein in the antecubital fossa for IV insertion based on its size and easily accessible location."
Correct Answer: B
Rationale: The correct technique for IV catheter insertion involves inserting the needle at a 10 to 30-degree angle with the bevel up. This angle facilitates proper vein puncture, reduces the risk of complications, and minimizes trauma to the vein. Choice A is incorrect because threading the needle into the vein at an angle of 10 to 30 degrees with the bevel up is the correct technique, not threading it all the way into the vein. Choice C is incorrect because applying pressure 1.2 inches below the insertion site before removing the needle is not a standard step in IV catheter insertion. Choice D is incorrect because selecting the antecubital fossa vein solely based on its size and accessibility may not be the most appropriate criterion; vein selection should also consider factors like vein condition and patient comfort.