Nokea
A nurse manager is providing an in-service to a group of newly licensed nurses about the use of personal protective equipment. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?
- A. I should wear a gown to remove linens from a client's be '
- B. Sterile gloves are required when administering an IM injection.'
- C. I should wear goggles when irrigating a woun '
- D. I should use both hands to recap a needle.'
Correct Answer: C
Rationale: The correct answer is C: "I should wear goggles when irrigating a wound." This indicates an understanding of the teaching as goggles protect the eyes from splashes and sprays. Wearing goggles during wound irrigation helps prevent potential eye exposure to contaminated fluids, reducing the risk of infection.
Choice A is incorrect because wearing a gown to remove linens is unnecessary for personal protective equipment during this task. Choice B is incorrect as sterile gloves are required for clean procedures like wound care, not for administering IM injections. Choice D is incorrect because using both hands to recap a needle increases the risk of needle-stick injuries.
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A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching?
- A. I should apply antibiotic ointment to the lesions.'
- B. I should use natural skin condoms during sexual intercourse.'
- C. I should expect my lesions to resolve in 6 weeks.'
- D. I should expect to take my medication for 3 weeks.'
Correct Answer: C
Rationale: The correct answer is C: "I should expect my lesions to resolve in 6 weeks." This indicates effectiveness of teaching because it shows the client understands the natural course of genital herpes and the expected timeline for resolution. Choice A is incorrect because antibiotic ointment is not recommended for herpes. Choice B is incorrect because natural skin condoms do not provide adequate protection against herpes. Choice D is incorrect because treatment duration may vary and is not always 3 weeks.
A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?
- A. Intrinsic factor
- B. Uric acid
- C. Chloride level
- D. Creatinine kinase
Correct Answer: B
Rationale: The correct answer is B: Uric acid. In acute gout, there is an accumulation of uric acid crystals in the joints, leading to inflammation and pain. As a result, the uric acid levels in the blood increase. Monitoring uric acid levels helps in diagnosing and managing gout.
Explanation for other choices:
A: Intrinsic factor - Intrinsic factor is related to vitamin B12 absorption, not gout.
C: Chloride level - Chloride level is not directly impacted by acute gout.
D: Creatinine kinase - Creatinine kinase is an enzyme related to muscle breakdown, not specifically affected by gout.
A nurse is providing teaching to a client who is scheduled for a bronchoscopy. Which of the following statements should the nurse include in the teaching?
- A. You will not be able to eat or drink after the procedure until you are able to cough.
- B. You will need to take deep breaths through your nose during the procedure.
- C. The procedure is painful
- D. and sedation will not be used.
- E. You will need to stay on bed rest for 24 hours after the procedure.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse should include the statement "You will not be able to eat or drink after the procedure until you are able to cough" because it is essential for the client's safety to prevent aspiration. After a bronchoscopy, the client may have an impaired gag reflex from the procedure, increasing the risk of choking. Therefore, it is crucial to wait until the gag reflex returns before eating or drinking. This statement emphasizes the importance of airway protection post-procedure.
Summary:
B: Incorrect - Breathing during a bronchoscopy is usually done through the mouth.
C: Incorrect - Bronchoscopy is uncomfortable but not typically painful due to sedation.
D: Incorrect - Sedation is commonly used during bronchoscopy to ensure client comfort.
E: Incorrect - Bed rest after a bronchoscopy is not typically necessary unless complications arise.
Which of the following actions should the nurse take? (Select all that apply)
- A. Anticipate client to be prepped for cardiac catheterization
- B. Assist with a continuous heparin infusion
- C. Encourage the client to ambulate
- D. Anticipate an increase in dosage of metoprolol
- E. Obtain a prescription for client to be NPO
- F. Request a prescription for an antibiotic
Correct Answer: A, B, D,E
Rationale: The correct actions for the nurse to take are A, B, D, and E. A - anticipating client prep for cardiac catheterization is important for timely intervention. B - assisting with a continuous heparin infusion helps prevent blood clot formation during the procedure. D - anticipating an increase in metoprolol dosage is necessary to manage cardiac workload during the procedure. E - obtaining a prescription for NPO status is crucial to prevent complications during the procedure. Choices C (encouraging ambulation) and F (requesting an antibiotic prescription) are not directly related to preparing for cardiac catheterization and may not be necessary in this context.
A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?
- A. Lethargy
- B. Hypotension
- C. Decreased heart rate
- D. Increased temperature
Correct Answer: D
Rationale: The correct answer is D: Increased temperature. In thyroid storm, there is excessive thyroid hormone production leading to hyperthyroidism symptoms, including increased body temperature. Lethargy (A) is more indicative of hypothyroidism. Hypotension (B) is not a typical finding in thyroid storm; instead, hypertension is more common. Decreased heart rate (C) is also not a common manifestation as tachycardia is typically present in thyroid storm. Therefore, option D is the most appropriate manifestation to recognize in thyroid storm.