Nokea
A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete before leaving the delivery room?
- A. Obtain the infant's vital signs.
- B. Observe the infant latching onto the breast.
- C. Administer a vitamin K injection.
- D. Place the ID bands on the infant and mother.
Correct Answer: D
Rationale: Placing ID bands on the infant and mother is crucial to ensure correct identification and prevent mix-ups. This step is essential for maintaining proper identification of the newborn and the mother, facilitating safe care delivery. Before leaving the delivery room, ensuring proper identification is a priority to prevent any errors. Obtaining the infant's vital signs may be important but does not take precedence over ensuring correct identification. Observing the infant latching onto the breast is crucial for breastfeeding initiation but can be done after proper identification. Administering a vitamin K injection is also important but should not delay the immediate identification process.
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A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that her voices are saying, "Kill, Kill." What question should the nurse ask the client next?
- A. When did these voices begin?
- B. Are you planning to obey the voices?
- C. Have you taken any hallucinogens?
- D. Do you believe the voices are real?
Correct Answer: B
Rationale: Assessing whether the client has a plan to act on the voices is critical for evaluating the risk of harm. Asking if the client is planning to obey the voices helps determine the immediate safety concerns. While understanding when the voices began could provide insight into the situation, assessing the intent to act on them is more urgent. Asking about hallucinogen use may be relevant but does not address the immediate safety issue. Inquiring about the client's belief in the reality of the voices is important but does not address the immediate risk of harm.
The client who had a below-the-knee (BKA) amputation is being prepared for discharge to home. Which recommendation should the nurse provide this client?
- A. Inspect skin for redness
- B. Use a residual limb shrinker
- C. Apply alcohol to the stump after bathing
- D. Wash the stump with soap and water
Correct Answer: D
Rationale: The correct recommendation for a client with a below-the-knee amputation preparing for discharge is to wash the stump with soap and water. This helps maintain cleanliness and prevent infection. Inspecting the skin for redness is important to monitor for signs of infection, but it is not a specific recommendation for a BKA amputation. Using a residual limb shrinker can aid in shaping and reducing swelling in the residual limb but is not usually done immediately after a BKA amputation. Applying alcohol to the stump after bathing is not recommended as it can lead to skin irritation and dryness.
Identify the placement of the stapes footplate into the bony labyrinth.
- A. Fenestra vestibuli
- B. Fenestra cochleae
- C. Tympanic membrane
- D. Round window
Correct Answer: A
Rationale: The correct answer is A: Fenestra vestibuli. The stapes footplate is placed into the fenestra vestibuli of the bony labyrinth. This structure is also known as the oval window and is located at the junction of the middle ear and inner ear. Choice B, Fenestra cochleae, is incorrect as this opening is also known as the round window and is located near the base of the cochlea. Choice C, Tympanic membrane, is incorrect as it is also known as the eardrum and separates the external ear from the middle ear. Choice D, Round window, is incorrect as it is the opening covered by the secondary tympanic membrane and is important for the dissipation of sound waves in the cochlea.
A client who had a cerebrovascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client's current health status?
- A. Risk for impaired tissue integrity related to impaired physical mobility
- B. Impaired skin integrity related to altered circulation and pressure
- C. Ineffective tissue perfusion related to inability to move self in bed
- D. Impaired physical mobility related to the left-side paralysis
Correct Answer: B
Rationale: The correct answer is B: 'Impaired skin integrity related to altered circulation and pressure.' This nursing diagnosis is the most appropriate as it directly addresses the Stage II pressure ulcer on the left hip, which is caused by altered circulation and pressure due to the client's left-side paralysis. Choice A is incorrect because it focuses on the risk for impaired tissue integrity rather than the current issue of impaired skin integrity. Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this scenario. Choice D is incorrect as it only addresses the left-side paralysis and not the pressure ulcer or altered circulation.
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?
- A. Call the radiology department
- B. Reinsert the implant into the vagina
- C. Apply double gloves to retrieve the implant for disposal
- D. Place the implant in a lead container using long-handled forceps
Correct Answer: D
Rationale: The correct action for the nurse to take when finding a radiation implant in the bed is to place the implant in a lead container using long-handled forceps. This action is crucial to minimize radiation exposure to both the patient and healthcare providers and ensure the safe disposal of the radioactive material. Calling the radiology department (choice A) may lead to unnecessary delays in addressing the immediate safety concern. Reinserting the implant into the vagina (choice B) is contraindicated and can cause harm. Applying double gloves to retrieve the implant for disposal (choice C) is not adequate for ensuring proper containment and handling of the radioactive implant, which requires specialized equipment like a lead container and long-handled forceps.