Nokea
During an admission interview, a nurse is assessing a client's personal identity. Which of the following questions should the nurse ask?
- A. What is your marital status?
- B. How would you describe yourself?
- C. Are you employed?
- D. Do you have any children?
Correct Answer: B
Rationale: When assessing personal identity, it is important to ask questions that prompt clients to describe themselves. Question B, 'How would you describe yourself?' is the most appropriate as it allows the client to share their own perceptions and characteristics, aiding in understanding their personal identity. Choices A, C, and D are more focused on specific personal details such as marital status, employment status, and parental status, which do not directly contribute to understanding personal identity.
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A client has a tracheostomy and requires suctioning. Which of the following actions should be taken?
- A. Hyperoxygenate the client before suctioning
- B. Insert the catheter while exhalation
- C. Apply suction after inserting the catheter
- D. Limit suctioning to no more than 15 seconds
Correct Answer: A
Rationale: Hyperoxygenating the client before suctioning is crucial to prevent hypoxia during the procedure. By using a manual resuscitation bag with 100% oxygen, the nurse should provide several breaths to the client to ensure sufficient oxygenation before starting suctioning. This approach helps maintain oxygen levels and decreases the risk of hypoxia, which may arise when suctioning interrupts the normal respiratory process. Choices B, C, and D are incorrect because inserting the catheter during exhalation, applying suction while inserting the catheter, and limiting suctioning to 15 seconds do not address the priority of hyperoxygenating the client to prevent hypoxia.
The nurse avoided a romantic tie with Mr. Gary. This is an example of?
- A. Professional boundaries
- B. Cultural sensitivity
- C. Justice
- D. Fidelity
Correct Answer: A
Rationale: Avoiding romance is professional boundaries (A) keeping limits, per ethics. Sensitivity (B) culture, justice (C) fairness, fidelity (D) promises not boundary-specific. A fits the nurse's ethical distance, ensuring professionalism, making it correct.
Select the 4 findings that require immediate follow-up.
- A. Lung sounds
- B. Capillary refill
- C. Client orientation
- D. Radial pulse characteristic
Correct Answer: D
Rationale: In a clinical scenario requiring immediate follow-up, nurses prioritize findings indicating potential deterioration or instability. Among the options lung sounds, capillary refill, client orientation, radial pulse characteristic, and others like vital signs or cough characteristics radial pulse characteristic (D) stands out as a critical indicator needing urgent attention if abnormal. An irregular, weak, or absent radial pulse could signal cardiovascular compromise, such as arrhythmia or shock, demanding immediate intervention. Lung sounds (A) are vital, but adventitious sounds alone don't always necessitate instant action unless paired with distress. Capillary refill (B) reflects perfusion, but a delay (e.g., >2 seconds) is concerning only in context. Client orientation (C) assesses neurological status, but subtle changes may not require immediate follow-up unless severe. The question asks for four findings, but the CSV limits to one correct answer, so D is chosen for its direct link to circulatory stability, a priority in emergencies. Rationale: Pulse abnormalities can precede life-threatening conditions like cardiac arrest, requiring swift assessment and action per ACLS guidelines, unlike the others which may escalate more gradually.
A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel is a key sign of bacterial meningitis in a 5-month-old, indicating increased intracranial pressure from infection, alongside fever, irritability, and seizures. Periorbital edema isn't typical, a positive Babinski is normal at this age, and a negative scarf sign relates to tone, not pressure. Nurses assess this bulging fontanel urgently, as it signals worsening inflammation, guiding immediate antibiotic and supportive care to prevent brain damage or death in this critical condition.
When admitting a client at risk for falls in a long-term care facility, what should the nurse do first?
- A. Complete a fall-risk assessment
- B. Place a fall-risk identification bracelet on the client
- C. Provide the client with nonskid footwear
- D. Set the bed to the lowest position
Correct Answer: A
Rationale: The initial step in caring for a client at risk for falls is to conduct a fall-risk assessment. This assessment helps the nurse gather crucial data to identify specific risks and individualized needs, guiding subsequent interventions and preventive measures. By completing a thorough assessment, the nurse can develop a targeted plan of care to mitigate fall risk and ensure the client's safety. Placing a fall-risk identification bracelet, providing nonskid footwear, or setting the bed to the lowest position may be important interventions, but these actions should be based on the findings of the fall-risk assessment, making choice A the priority.