Nokea
An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?
- A. The AP hangs the collection bag below the level of the bladder.
- B. The AP performs hand hygiene before handling the catheter.
- C. The AP secures the catheter to the client's leg with tape.
- D. The AP empties the collection bag when it is full.
Correct Answer: A
Rationale: Hanging the collection bag below the level of the bladder is the correct technique for maintaining proper drainage and preventing backflow in a client with an indwelling urinary catheter. Therefore, choice A is the correct answer as it indicates a need for further teaching. Choices B, C, and D demonstrate appropriate actions in catheter care. Performing hand hygiene before handling the catheter helps prevent infection, securing the catheter to the client's leg with tape prevents accidental dislodgement, and emptying the collection bag when it is full ensures that the catheter functions effectively.
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A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission, the peak flow meter is measured at 480 liters/minute. Post-operatively, the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first?
- A. Notify the healthcare provider
- B. Administer the PRN dose of Albuterol
- C. Apply oxygen at 2 liters per nasal cannula
- D. Repeat the peak flow reading in 30 minutes
Correct Answer: B
Rationale: In a client with moderate persistent asthma experiencing a drop in peak flow and chest tightness post-operatively, the first action the nurse should take is to administer the PRN dose of Albuterol. Albuterol is a short-acting bronchodilator that helps relieve bronchospasm and improve breathing. Notifying the healthcare provider (choice A) can be done after initiating immediate treatment with Albuterol. Applying oxygen (choice C) may be necessary but addressing the bronchospasm with Albuterol is the priority. Repeating the peak flow reading (choice D) can be considered after administering Albuterol to assess the response to treatment.
After inserting an NG tube for a client, which of the following assessment findings should the nurse expect to confirm correct tube placement?
- A. An x-ray shows the end of the tube above the pylorus.
- B. The tube is aspirated and contains clear gastric fluid.
- C. The tube is flushed with sterile water without resistance.
- D. The client does not cough or choke during tube insertion.
Correct Answer: B
Rationale: Correct placement of an NG tube is confirmed by aspirating gastric fluid, which indicates that the tube is in the stomach. An x-ray can help visualize tube placement, but it alone does not confirm correct placement. Flushing the tube with sterile water without resistance indicates patency but not necessarily correct placement. The absence of coughing or choking does not confirm tube placement and is more related to the client's comfort during the procedure.
An elderly client who requires frequent monitoring fell and fractured a hip. Which LPN/LVN is at greatest risk for a malpractice judgment?
- A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
- B. The nurse assigned to care for the client who was at lunch at the time of the fall.
- C. The nurse who transferred the client to the chair when the fall occurred.
- D. The charge nurse who completed rounds 30 minutes before the fall occurred.
Correct Answer: C
Rationale: The nurse who transferred the client to the chair when the fall occurred is directly involved in the event that led to the injury. Improper transfer techniques or lack of appropriate precautions during the transfer could have contributed to the fall and subsequent fracture of the hip. This direct involvement makes this nurse the one at greatest risk for a malpractice judgment. Choices A, B, and D are not as directly linked to the event that caused the injury. While poor nursing notes could be a factor, it is the immediate action of transferring the client that has a more direct impact on the client's fall and subsequent injury.
During a neurologic examination, which assessment should a nurse perform to test a client's balance?
- A. Romberg test
- B. Heel-to-toe walk
- C. Snellen test
- D. Spinal accessory function
Correct Answer: A
Rationale: The Romberg test is used to assess a client's balance by evaluating their ability to maintain a steady posture with eyes closed. The heel-to-toe walk is another assessment that tests balance by assessing gait and coordination. The Snellen test is used to assess visual acuity and is unrelated to balance. Testing spinal accessory function involves assessing the movement of the head and shoulders and is not directly related to balance assessment.
A client is hospitalized for an infection of a surgical wound following abdominal surgery. To promote healing and fight wound infection, the nurse plans to arrange to increase the client's intake of:
- A. Vitamin C and Zinc
- B. Vitamin B12 and Calcium
- C. Vitamin D and Iron
- D. Vitamin A and Potassium
Correct Answer: A
Rationale: The correct answer is A: Vitamin C and Zinc. Vitamin C is essential for collagen synthesis, which is important for wound healing. Zinc plays a crucial role in immune function and also aids in wound healing. Vitamin B12 and Calcium (Choice B) are not directly associated with wound healing properties. Vitamin D and Iron (Choice C) are important for overall health but are not specifically targeted for wound healing. Vitamin A and Potassium (Choice D) do not have direct wound healing properties and are not the best choices to promote wound healing and fight infection.