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After going through the necessary procedures for collecting physical evidence after a rape, a client is crying and talking about what happened to her. The nurse should:
- A. Advise the client to try to forget about what happened
- B. Recommend that the client be thankful for the fact that she's alive
- C. Question the client about what she could have done to deter the attack
- D. Listen to the client's descriptions about what occurred
Correct Answer: D
Rationale: Listening to the client's descriptions provides emotional support and validates her experience, which is therapeutic post-trauma. Other responses may minimize or blame the client.
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The nurse instills 5 mL of normal saline before suctioning a client's tracheostomy tube. The instillation is effective when:
- A. The secretions are thinned.
- B. The client coughs.
- C. There is minimal friction when the catheter is passed into the tracheostomy tube.
- D. There is humidification for the respiratory tract.
Correct Answer: A
Rationale: Instilling normal saline thins secretions, facilitating effective suctioning of the tracheostomy tube.
During the admission interview, an adult client reveals that, as a child, she was sexually abused by her uncle and a male cousin. She reports that she cuts the skin of her arms, legs, and abdomen. In addition to having the client sign a no-harm contract, which nursing intervention is most important?
- A. Assist the client with finding safe ways to express her anger.
- B. Talk with the client about confronting her uncle and cousin directly.
- C. Defer talking about the abuse to prevent further self-mutilation.
- D. Discuss the possibility of the client suing her relatives for their abuse.
Correct Answer: A
Rationale: Helping the client find safe ways to express anger addresses the self-harm behavior therapeutically, promoting coping skills and safety.
The nurse is preparing to suction a tracheostomy for a client with methicillin resistant staphylococcus aureus (MRSA) (see fi gure). The nurse should:
- A. Wear a powered air purifying respirator (PAPR) face shield.
- B. Use goggles that include the hairline.
- C. Change to a surgical mask.
- D. Proceed to suction the client’s tracheostomy.
Correct Answer: D
Rationale: The nurse is wearing protective personnel equipment appropriately for suctioning the client: goggles, gown and respirator mask. It is not necessary to wear a powered air purifying respirator face shield to suction a tracheostomy. A surgical mask does not provide maximum protection.
A client with type 1 diabetes mellitus is admitted with symptoms of hyperglycemia. Which laboratory finding should the nurse expect?
- A. Blood glucose of 90 mg/dL.
- B. Serum pH of 7.45.
- C. Ketones present in urine.
- D. Serum potassium of 5.5 mEq/L.
Correct Answer: C
Rationale: Hyperglycemia in type 1 diabetes often leads to diabetic ketoacidosis, with ketones in the urine due to fat metabolism, a key finding to monitor.
Which of the following security concerns is also a sentinel event that must be reported?
- A. A possible vulnerability of the facility's information technology to hacking
- B. The assisted suicide of a client in your facility by the spouse of the client
- C. Vulnerability to computer hacking
- D. Potential information theft
Correct Answer: B
Rationale: The assisted suicide of a client is a sentinel event, as it is an unexpected occurrence involving death, requiring immediate investigation and reporting per The Joint Commission standards.