Nokea
0800:
The client is alert and oriented to person, place, and time. Seizure pads placed on the client's bed. Suction equipment is at the client's bedside and functioning. Oxygen equipment is at the client's bedside.
1000:
Client is in bed and reports experiencing an aura, followed by generalized jerking contractions of arms and legs. Client incontinent of urine and unresponsive to commands.
1004:
Client's jerking contractions of arms and legs stopped. Client is confused and lethargic. Bilateral breath sounds clear. Oxygen applied 3 L/min via nasal cannula. Oxygen saturation 95%.
At 1000 the nurse enters the client's room. The first action the nurse should take is followed by
- A. Remove the pillows
- B. Turn the client to their side
- C. call for emergency assistance
- E. initiate IV fluids
- F. document seizure
- G. prepare medications
Correct Answer: A,B
Rationale: Removing pillows prevents airway obstruction; turning to the side aids drainage during a seizure.
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A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.
- A. Prepare a dry work surface above the waist level.
- B. Open the outside cover of the sterile kit and remove the dust cover.
- C. Grasp the outermost flap of the sterile kit while opening away from the body.
- D. Open each side flap of the sterile kit individually while pulling to the side.
- E. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
Correct Answer: A,B,C,D,E
Rationale: This sequence (A,B,C,D,E) maintains sterility by preparing, opening away, and avoiding contamination.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Provide the teaching without expecting the client to respond.
- B. Speak with a loud voice while providing the information.
- C. Avoid the use of facial gestures during the instructions.
- D. Determine the client's ability to use a communication board.
Correct Answer: D
Rationale: A communication board aids expression in expressive aphasia, enhancing understanding.
A nurse is caring for a client and observes a nurse from another unit reviewing the client's medical record. Which of the following actions should the nurse take?
- A. Complete an incident report about the breach of confidentiality.
- B. Tell the nurse that permission from the risk manager is required to view the client's record.
- C. Remind the nurse that only staff caring for the client may access the client's record.
- D. Contact facility security to remove the nurse from the unit.
Correct Answer: C
Rationale: Reminding about access protocol directly addresses unauthorized viewing, maintaining confidentiality per HIPAA.
A nurse is caring for a client who has dyspnea with an oxygen saturation of 88%. Which of the following indicates the type of face mask the nurse should use to deliver the client a 90% oxygen concentration?
- A. Simple face mask
- B. Nasal prongs
- C. Non-rebreather mask
- D. Nasal cannula
Correct Answer: C
Rationale: A non-rebreather mask delivers up to 90-100% oxygen, ideal for raising saturation.
A nurse is reinforcing a teaching plan regarding proper lifting with a client. Which of the following strategies should the nurse include to prevent back injury when lifting an object?
- A. Keep legs straight.
- B. Bend at the waist.
- C. Hold object away from the body.
- D. Tighten the abdominal muscles.
Correct Answer: D
Rationale: Tightening abdominal muscles stabilizes the core, reducing back strain during lifting.