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 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 caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?
- A. Decreased anxiety
- B. Emesis of 250 mL
- C. Increased respiratory rate to 26/min
- D. Decreased urinary output
Correct Answer: A
Rationale: The correct answer is A: Decreased anxiety. Morphine is often used to relieve pain and anxiety in patients with acute heart failure. The nurse should expect a reduction in anxiety as a positive response to the medication. Emesis (choice B) is not a typical indication of morphine effectiveness. Increased respiratory rate (choice C) may indicate respiratory depression, a potential adverse effect of morphine. Decreased urinary output (choice D) could suggest decreased cardiac output, which is not necessarily a sign of morphine effectiveness in this case.
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber
- B. Intermittent bubbling in the suction chamber
- C. Clear drainage of 50 mL over 8 hours
- D. Mild pain at the insertion site
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber indicates an air leak in the chest tube system, which can lead to lung collapse or pneumothorax. This finding should be reported to the provider immediately for further evaluation and intervention. Intermittent bubbling in the suction chamber (choice B) is expected and indicates that the suction is working properly. Clear drainage of 50 mL over 8 hours (choice C) is within normal limits and does not require immediate reporting. Mild pain at the insertion site (choice D) is common after a chest tube insertion and can be managed with pain medication.
A nurse is caring for a client who has oral achalasia, The nurse should ask the client which of the following questions to assess their ability to swallow?
- A. Do you feel like you have food stuck at the base of your throat?'
- B. Do you have any feelings of fullness in the neck?'
- C. Do you feel any burning sensations in your throat?'
- D. Do you have any problems with pain while swallowing?'
Correct Answer: A
Rationale: The correct answer is A: "Do you feel like you have food stuck at the base of your throat?" This question is appropriate for assessing the client's ability to swallow because oral achalasia is a condition where the lower esophageal sphincter fails to relax, causing difficulty in passing food from the mouth to the esophagus. Asking about the sensation of food stuck in the throat helps to identify this symptom.
Choice B: "Do you have any feelings of fullness in the neck?" is incorrect because fullness in the neck is not a typical symptom of oral achalasia.
Choice C: "Do you feel any burning sensations in your throat?" is incorrect because burning sensations are more commonly associated with acid reflux or GERD, not specifically with oral achalasia.
Choice D: "Do you have any problems with pain while swallowing?" is incorrect as pain while swallowing is not a typical symptom of oral achalasia.
Therefore, the correct question to assess
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
- A. Photophobia
- B. Bradycardia
- C. Intermittent headache
- D. Petechiae on the chest
Correct Answer: A
Rationale: The correct answer is A: Photophobia. Meningitis is an inflammation of the meninges, the protective membranes covering the brain and spinal cord. Photophobia, or sensitivity to light, is a classic symptom of meningitis due to the irritation of the meninges causing increased sensitivity to light. This occurs because the inflamed meninges lead to stimulation of the nerves around the brain, resulting in discomfort when exposed to light.
Bradycardia (B) is not typically associated with meningitis. Intermittent headache (C) is vague and can be present in various conditions. Petechiae on the chest (D) are more commonly seen in conditions like meningococcal meningitis.