Nokea
An adult client is found to be unresponsive during morning rounds. After checking for responsiveness and calling for help, what should the nurse do next?
- A. Check the carotid pulse
- B. Deliver 5 abdominal thrusts
- C. Give 2 rescue breaths
- D. Open the client's airway
Correct Answer: D
Rationale: After confirming unresponsiveness and calling for help, the next step in basic life support is to open the client's airway. This ensures that the airway is clear and allows for effective ventilation. Checking the carotid pulse is not necessary at this stage as airway management takes precedence. Delivering abdominal thrusts is not indicated for an unresponsive client as it is for conscious choking individuals. Giving rescue breaths should only be done after ensuring the airway is open to allow for effective ventilation.
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A healthcare professional is preparing to administer IV fluids to a client. The professional notes sparks when plugging in the IV pump. Which of the following actions should the professional take first?
- A. Label the pump with a defective equipment sticker.
- B. Unplug the pump.
- C. Obtain a replacement pump.
- D. Notify the maintenance department to fix the pump.
Correct Answer: B
Rationale: Unplugging the pump is the correct initial action in this situation to prevent any potential fire hazards. Sparks when plugging in the IV pump indicate an electrical issue that can lead to a fire. By immediately unplugging the pump, the healthcare professional ensures the safety of the client and prevents any further risks. Labeling the pump with a defective equipment sticker (Choice A) is not the priority as the immediate concern is safety. Obtaining a replacement pump (Choice C) can be considered after addressing the safety issue. Notifying the maintenance department (Choice D) is important but should follow the immediate action of unplugging the pump to mitigate the risk.
When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to
- A. Change whichever item is incorrect to the correct information
- B. Use the bracelet and admission form until a replacement is supplied
- C. Notify the admissions office and wait to apply the bracelet
- D. Make a corrected identification bracelet for the client
Correct Answer: C
Rationale: The nurse should notify the admissions office and wait to apply the bracelet. By doing so, the nurse ensures patient safety and accuracy in identification. Changing the incorrect item (Choice A) could lead to errors and confusion in the patient's identification. Using the mismatched items until a replacement is supplied (Choice B) compromises patient safety and could result in errors during care delivery. Making a corrected identification bracelet without verifying the correct information (Choice D) could introduce further inaccuracies and risks in patient identification.
When assisting an older adult client with dysphagia following a CVA during mealtime, what should the nurse prioritize?
- A. Offer the client tart or sour foods.
- B. Ensure the client is sitting upright while eating.
- C. Provide soft and easily swallowable foods.
- D. Give the client thickened liquids to help with swallowing.
Correct Answer: B
Rationale: The correct answer is to ensure the client is sitting upright while eating. This position helps prevent aspiration and facilitates swallowing. Offering tart or sour foods (Choice A) may not be suitable for someone with dysphagia as they can be difficult to swallow and may increase the risk of aspiration. Providing soft and easily swallowable foods (Choice C) is crucial for individuals with swallowing difficulties. While giving thickened liquids (Choice D) is a common intervention for dysphagia, the priority during mealtime should be ensuring the client's proper positioning to support safe swallowing and prevent aspiration.
A client with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client is short of breath and has a pulse oximetry reading of 88%. What action should the LPN take first?
- A. Increase the oxygen flow rate to 4 liters per minute.
- B. Reposition the client to a high Fowler's position.
- C. Notify the healthcare provider of the client's condition.
- D. Encourage the client to use pursed-lip breathing.
Correct Answer: B
Rationale: Repositioning the client to a high Fowler's position should be the first action taken by the LPN. This position helps improve oxygenation by maximizing lung expansion, making it easier for the client to breathe. Increasing the oxygen flow rate without addressing positioning may not fully optimize oxygen delivery. Notifying the healthcare provider should come after immediate interventions. Encouraging pursed-lip breathing is beneficial but should follow the initial positioning to further assist the client in managing their breathing difficulty.
The healthcare professional is preparing to administer a tuberculin skin test. Which site is most appropriate for this injection?
- A. Deltoid muscle
- B. Vastus lateralis muscle
- C. Abdomen
- D. Inner forearm
Correct Answer: D
Rationale: The inner forearm is the most appropriate site for administering a tuberculin skin test. This test requires an intradermal injection, which is administered just below the surface of the skin. The inner forearm provides a flat, easily accessible surface for this type of injection. Choices A, B, and C are incorrect because the tuberculin skin test should not be administered into a muscle (deltoid muscle or vastus lateralis muscle) or into the abdomen. The test requires precise placement within the dermal layer of the skin on the inner forearm to accurately assess for a reaction.