Nokea
A school nurse is discussing poison prevention and management with a group of parents. Which statement by parents would indicate a need for additional teaching?
- A. Containers of poisonous liquids need to be properly labeled.
- B. In the event gasoline is ingested by my child, vomiting should be induced.
- C. I may be able to give my child milk or water to dilute a corrosive poison while I rush them to the hospital.
- D. All poisonous materials should be securely stored away from children.
Correct Answer: B
Rationale: Inducing vomiting for gasoline ingestion is dangerous due to aspiration risk. Labeling, diluting corrosives (if advised), and secure storage are correct.
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The nurse assesses a client's central venous catheter dressing, and it appears loose and wet. The nurse should take which action?
- A. Reinforce the dressing with paper tape
- B. Remove the dressing and the central vascular device
- C. Apply a clean occlusive dressing to the site
- D. Clean the site and apply a new sterile dressing
Correct Answer: D
Rationale: Cleaning the site and applying a new sterile dressing prevents infection and ensures catheter security.
The nurse participates in a task force to reduce errors related to telephone and verbal orders. The nurse should recommend that
- A. unlicensed assistive personnel (UAP) can take a physician's telephone prescription.
- B. use more abbreviations when transcribing a physician's order.
- C. when repeating an order back to the physician, repeat the numbers individually.
- D. verbal and telephone orders are limited to emergency situations.
- E. transcribing telephone and verbal orders be delayed until a second nurse can review the order.
Correct Answer: C,D
Rationale: Repeating numbers individually and limiting verbal orders to emergencies reduce errors. UAP cannot take prescriptions, abbreviations increase errors, and delays risk patient safety.
The nurse plans care for a client immediately post-operative. The nurse should initially assess the client's
- A. respiratory status
- B. tolerance to by-mouth (PO) fluids
- C. pain level
- D. ability to move the extremities
Correct Answer: A
Rationale: Respiratory status is the priority assessment post-operatively to ensure airway patency and adequate oxygenation, following the ABCs (airway, breathing, circulation) of care. Pain, fluid tolerance, and extremity movement are important but secondary to ensuring respiratory stability.
The nurse is assisting a client in selecting appropriate food options for dumping syndrome. Which foods would be suitable choices? Select all that apply.
- A. Rice cereal
- B. Pastries
- C. Chicken breast
- D. Cola
- E. Scrambled eggs
Correct Answer: A,C,E
Rationale: Rice cereal, chicken breast, and scrambled eggs are low-sugar, high-protein options suitable for dumping syndrome. Pastries and cola are high-sugar, triggering symptoms.
The nurse cares for a client with a double-lumen peripherally inserted central catheter (PICC). Which of the following actions would be appropriate for the nurse to take?
- A. Assign the client to a private room.
- B. Change the dressing daily using sterile technique.
- C. Flush heparin prior to discontinuation.
- D. Aspirate each lumen for blood return and then flush.
Correct Answer: D
Rationale: Aspirating for blood return and flushing ensures PICC patency. Private rooms, daily dressing changes, and heparin flushing are not standard unless specified.