Nokea
A nurse needs to draw a blood sample from a patient's central line. The line is currently infusing Ringer's lactate. In which order should the nurse take the following steps to draw the blood sample? Number the steps below.
- A. attach the flush syringe and flush catheter with normal saline
- B. stop the infusion and disconnect Ringer's lactate
- C. withdraw a blood sample and discard
- D. scrub the catheter hub
- E. withdraw the blood sample for the lab
Correct Answer: B,D,C,A,E
Rationale: Order: Stop infusion (B), scrub hub (D), withdraw/discard blood (C), flush with saline (A), withdraw lab sample (E). This ensures a clean, accurate sample.
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What is the responsibility of the nurse in obtaining an informed consent for surgery?
- A. Describing in a clear and simply stated manner what the surgery will involve
- B. Explaining the benefits, alternatives, and possible risks and complications of surgery
- C. Using the nurse/client relationship to persuade the client to sign the operative permit
- D. Providing the informed consent for surgery and witnessing the client's signature
Correct Answer: D
Rationale: The nurse's role is to witness the client's signature and ensure the consent form is completed, not to explain the procedure.
A neonate has severe congenital abnormalities that make death imminent, and the NICU team believes that further attempts at treatment or feeding are not warranted and that palliative care only should be provided. When speaking with the parents about this, which of the following is the best approach?
- A. Tell the parents that the team suggests that all food and treatment will be withheld.
- B. Tell the parents that the team suggests a change in care plan to focus on comfort measures.
- C. Tell the parents that any further efforts at treatment are futile as the infant is dying.
- D. Tell the parents that the best thing is to let nature take its course.
Correct Answer: B
Rationale: Focusing on comfort measures (B) communicates compassionately that palliative care prioritizes the neonate's comfort, aligning with the parents' emotional needs. Withholding food/treatment (A) is harsh, futility (C) is blunt, and letting nature take its course (D) lacks clarity.
The nurse is caring for a client who is postoperative day 1 following a total hip replacement. Which of the following positions should the nurse AVOID placing the client in?
- A. Supine with legs abducted.
- B. High Fowler’s with legs extended.
- C. Side-lying on the unaffected side.
- D. Prone with legs adducted.
Correct Answer: D
Rationale: prone position with legs adducted can cause hip dislocation; abduction is maintained post-hip replacement
The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
- A. I will make sure I eat breakfast within 10 minutes of taking my insulin.
- B. I will need to carry candy or some form of sugar with me all the time.
- C. I will eat a snack around three o'clock each afternoon.
- D. I can save my dessert from supper for a bedtime snack.
Correct Answer: C
Rationale: Novolog insulin peaks around 1-3 hours after administration, so a snack around 3 PM aligns with the peak to prevent hypoglycemia.
The client presents to the emergency room with a 'bull's eye' rash. Which question would be most appropriate for the nurse to ask the client?
- A. Have you found any ticks on your body?'
- B. Have you had any nausea in the last 24 hours?'
- C. Have you been outside the country in the last 6 months?'
- D. Have you had any fever for the past few days?'
Correct Answer: A
Rationale: A bull's eye rash is characteristic of Lyme disease, often caused by tick bites, making this the most relevant question.