Nokea
During an IV catheter insertion demonstration, which statement by a nurse indicates understanding of the procedure?
- A. "I will thread the needle into the vein at an angle of 10 to 30 degrees with the bevel up."
- B. "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up."
- C. "I will apply pressure approximately 1.2 inches below the insertion site before removing the needle."
- D. "I will select a vein in the antecubital fossa for IV insertion based on its size and easily accessible location."
Correct Answer: B
Rationale: The correct technique for IV catheter insertion involves inserting the needle at a 10 to 30-degree angle with the bevel up. This angle facilitates proper vein puncture, reduces the risk of complications, and minimizes trauma to the vein. Choice A is incorrect because threading the needle into the vein at an angle of 10 to 30 degrees with the bevel up is the correct technique, not threading it all the way into the vein. Choice C is incorrect because applying pressure 1.2 inches below the insertion site before removing the needle is not a standard step in IV catheter insertion. Choice D is incorrect because selecting the antecubital fossa vein solely based on its size and accessibility may not be the most appropriate criterion; vein selection should also consider factors like vein condition and patient comfort.
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An older adult client appears agitated when the nurse requests that the client's dentures be removed prior to surgery and states, "I never go anywhere without my teeth." Which of the following is an appropriate nursing response?
- A. You should comply with the request
- B. You seem worried. Are you concerned someone may see you without your teeth?
- C. I will call your family to discuss this
- D. It's not a big deal; just remove them
Correct Answer: B
Rationale: The appropriate nursing response in this situation is to acknowledge and address the client's concerns empathetically. By expressing understanding and asking if the client is worried about being seen without their teeth, the nurse shows empathy and attempts to alleviate the client's anxiety. Choice A is incorrect as it dismisses the client's feelings. Choice C is inappropriate as it does not directly address the client's agitation. Choice D is not the best response as it minimizes the client's feelings and does not provide emotional support.
The healthcare provider is monitoring a client in active labor. Which pattern on the fetal heart monitor requires immediate intervention?
- A. Early decelerations
- B. Late decelerations
- C. Accelerations
- D. Moderate variability
Correct Answer: B
Rationale: Late decelerations are concerning as they indicate uteroplacental insufficiency, potentially resulting in fetal hypoxia. Immediate intervention is necessary to address the underlying cause and ensure fetal well-being. Early decelerations are typically benign and associated with head compression during contractions. Accelerations are reassuring and indicate fetal well-being. Moderate variability is a normal finding and indicates a healthy autonomic nervous system response. Therefore, late decelerations (Choice B) require immediate attention, while the other patterns are generally considered normal or benign during labor.
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
- A. Ask another nurse to observe the medication wastage
- B. Notify the pharmacy when wasting the medication
- C. Lock the remaining medication in the controlled substance cabinet
- D. Dispose of the vial with the remaining medication in a sharps container
Correct Answer: A
Rationale: In medication wastage situations involving controlled substances, it is crucial to have a second nurse observe and verify the disposal process. This practice ensures accountability and prevents any mishandling or diversion of the medication. Choice B is incorrect because notifying the pharmacy is not the immediate action required in this scenario. Choice C is incorrect as locking the remaining medication in the controlled substance cabinet without proper witnessing does not ensure accountability. Choice D is incorrect as disposing of the vial with the remaining medication in a sharps container does not address the need for a witness to verify the wastage of the controlled substance.
A nurse in a provider's office is collecting data from the caregiver of a 12-month-old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains?
- A. Cognitive
- B. Affective
- C. Psychomotor
- D. Kinesthetic
Correct Answer: B
Rationale: The correct answer is B: Affective. The caregiver's decision to postpone toilet training indicates a change in feelings or attitudes, which falls under the affective domain of learning. The affective domain relates to emotions, values, and attitudes. In this scenario, the caregiver's willingness to delay toilet training due to new information reflects a shift in attitude impacted by the educational session provided by the nurse. Choices A, C, and D are incorrect. The cognitive (choice A) domain involves intellectual skills and knowledge, the psychomotor (choice C) domain involves physical skills, and kinesthetic (choice D) is often used interchangeably with the psychomotor domain, which focuses on physical movement and coordination.
A client with chronic renal failure selects scrambled eggs for breakfast. What action should the LPN/LVN take?
- A. Commend the client for selecting a high biological value protein.
- B. Remind the client that protein in the diet should be avoided.
- C. Suggest that the client also select orange juice to promote absorption.
- D. Encourage the client to attend classes on dietary management of chronic renal failure.
Correct Answer: A
Rationale: The correct action is to commend the client for selecting a high biological value protein, as scrambled eggs provide a good protein source for clients with chronic renal failure. Protein is essential for maintaining muscle mass and overall health in these clients. Reminding the client to avoid protein is incorrect as it may lead to protein-energy malnutrition, which is a common concern in chronic renal failure. Suggesting orange juice for absorption is not relevant to the situation, as protein absorption is not a primary concern in this context. Encouraging the client to attend classes on dietary management of chronic renal failure is important for overall education but is not the immediate action needed in response to the client's breakfast choice.