Nokea
A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?
- A. Conduct staff communications away from the client's room.
- B. Avoid entering the client's room unless requested during the night.
- C. Turn on the client's TV to distract from hallway noise.
- D. Turn off alarms on bedside monitoring equipment.
Correct Answer: A
Rationale: Reducing noise near the client’s room promotes a sleep-friendly environment.
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A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
- A. Removing the client's dentures from their mouth
- B. Washing the client's face
- C. Closing the client's eyes
- D. Gathering the client's personal belongings
Correct Answer: A
Rationale: Removing dentures is a nursing task to ensure proper handling, requiring intervention.
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)
- A. Squeeze the client's finger until a blood drop forms.
- B. Apply clean gloves.
- C. Prick the side of the client's finger.
- D. Elevate the client's hand above the level of the heart.
- E. Cleanse the client's finger with an iodine swab.
Correct Answer: B,C,E
Rationale: B: Gloves ensure infection control. C: Side prick is correct technique. E: Iodine disinfects; A risks hemolysis, D impedes flow.
A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Apply the belt restraint over the client's gown.
- B. Make sure four fingers fit between the restraint and the client's body.
- C. Check the client's skin integrity every 4 hr.
- D. Tie the belt restraint to the side rail of the bed.
Correct Answer: A
Rationale: Applying restraints over clothing prevents skin irritation and adds comfort, reducing risks of abrasions and pressure sores.
A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
- A. Inflate the catheter's balloon.
- B. Lower the penis to a 45° angle.
- C. Apply lidocaine gel to the urethra.
- D. Twist the catheter gently.
Correct Answer: D
Rationale: Gentle twisting can navigate urethral obstructions safely without causing trauma.
0800:
The client is alert and oriented to person, place, and time. Seizure pads placed on the client's bed. Suction equipment is at the client's bedside and functioning. Oxygen equipment is at the client's bedside.
1000:
Client is in bed and reports experiencing an aura, followed by generalized jerking contractions of arms and legs. Client incontinent of urine and unresponsive to commands.
1004:
Client's jerking contractions of arms and legs stopped. Client is confused and lethargic. Bilateral breath sounds clear. Oxygen applied 3 L/min via nasal cannula. Oxygen saturation 95%.
At 1000 the nurse enters the client's room. The first action the nurse should take is followed by
- A. Remove the pillows
- B. Turn the client to their side
- C. call for emergency assistance
- E. initiate IV fluids
- F. document seizure
- G. prepare medications
Correct Answer: A,B
Rationale: Removing pillows prevents airway obstruction; turning to the side aids drainage during a seizure.