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During a home safety assessment for a client receiving supplemental oxygen, which observation should the nurse identify as proper safety protocol?
- A. The client uses non-acetone nail polish remover.
- B. The client uses an electric razor for shaving.
- C. The client cleans their oxygen equipment weekly.
- D. The client uses wool blankets.
Correct Answer: A
Rationale: The correct answer is A. Using non-acetone nail polish remover is crucial for clients on supplemental oxygen as acetone is flammable and poses a safety risk. Acetone can react with oxygen, increasing the fire hazard. Choices B, C, and D are incorrect. Electric razors can generate sparks, which are dangerous near oxygen due to the risk of ignition. While cleaning oxygen equipment is important, the type of nail polish remover used is more critical for immediate safety. Wool blankets can create static electricity, increasing the risk of fire around oxygen due to its flammability.
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A nurse on a med-surg unit is teaching a newly licensed nurse about tasks to delegate to APs. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. An AP may take orthostatic blood pressure measurements from a client who reports dizziness.
- B. An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids.
- C. An AP may perform a central line dressing change for a client who is ready for discharge.
- D. An AP may ambulate a client who had a stroke 2 days ago.
Correct Answer: D
Rationale: The correct answer is D. Delegating the task of ambulating a client who had a stroke 2 days ago to an AP is appropriate. This task falls within the scope of practice for an AP and can help promote mobility and prevent complications. Choices A, B, and C involve more complex nursing assessments or procedures that require a higher level of training and expertise. Taking orthostatic blood pressure measurements, monitoring a peripheral IV insertion site, and performing a central line dressing change should be tasks performed by licensed nurses to ensure proper assessment and management of the client's condition.
A client with a terminal illness is being educated by a healthcare provider about her decision to decline resuscitation in her living will. The client asks about the scenario of having difficulty breathing upon arrival at the emergency department.
- A. "We will apply oxygen through a tube in your nose."
- B. "We will perform resuscitation efforts regardless of your wishes."
- C. "You will receive only palliative care."
- D. "We will ensure your comfort measures are met as per your advance directives."
Correct Answer: A
Rationale: Choice A is correct because applying oxygen through a tube in the nose provides comfort and aligns with the client's wishes for palliative care without resuscitation. This intervention can help alleviate breathing difficulties and maintain comfort without initiating full resuscitation efforts, respecting the client's decision. Choice B is incorrect as it goes against the client's expressed wish to decline resuscitation in her living will. Choice C is not the most appropriate response as it does not directly address the client's immediate concern of difficulty breathing and lacks specificity. Choice D, although focusing on comfort measures, is less specific than the correct choice A in addressing the client's immediate need for assistance with breathing.
The nurse is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states 'clean the wound and then apply collagenase.' Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse use to cleanse the pressure ulcer?
- A. Lightly coat the wound with povidone-iodine solution
- B. Irrigate the wound with sterile normal saline
- C. Flush the wound with sterile hydrogen peroxide
- D. Remove the eschar with a wet-to-dry dressing
Correct Answer: B
Rationale: Irrigating the wound with sterile normal saline is the correct technique for cleansing a wound when the prescription does not specify a cleaning method. Sterile normal saline is a standard and safe solution that helps to remove debris and promote healing without damaging healthy tissue. Choice A, using povidone-iodine solution, can be cytotoxic and delay wound healing. Choice C, using hydrogen peroxide, can be cytotoxic, cause tissue damage, and delay wound healing. Choice D, using wet-to-dry dressing to remove eschar, is an outdated and non-selective method that can cause trauma to the wound bed and delay healing. Therefore, choice B is the best option for wound cleansing in this scenario.
When demonstrating an empathic presence to a client, which of the following actions should the nurse take?
- A. Use an open posture
- B. Write down what the client says for accurate documentation
- C. Establish and maintain eye contact
- D. Nod in agreement with the client throughout the conversation
Correct Answer: A
Rationale: Using an open posture is crucial when demonstrating empathy to a client. This body language conveys openness, understanding, and a willingness to listen, creating a safe space for the client to express themselves. Establishing and maintaining eye contact is also important as it fosters a sense of connection and validation for the client. Writing down what the client says is essential for accurate documentation and memory but does not directly contribute to demonstrating empathic presence. Nodding in agreement with the client throughout the conversation may show attentiveness, but it does not necessarily reflect empathy or active listening as it could be misinterpreted as simply agreeing with what is being said.
A healthcare professional is caring for a client who has a prescription for a vest restraint. Which of the following actions should the healthcare professional take?
- A. Tie the restraint with a quick-release knot.
- B. Use a slipknot to secure the restraint.
- C. Ensure the restraint is tightly secured.
- D. Attach the restraint to the bed frame.
Correct Answer: A
Rationale: The correct action for the healthcare professional to take when applying a vest restraint is to tie it with a quick-release knot. A quick-release knot allows for easy and rapid removal in case of an emergency, ensuring the safety of the client. Using a slipknot (Choice B) is not recommended as it may not provide quick release in emergencies. Ensuring the restraint is tightly secured (Choice C) can be dangerous as it can restrict circulation or cause discomfort. Attaching the restraint to the bed frame (Choice D) is inappropriate and can lead to potential harm or injury to the client.