Nokea
Following a detailed conversation between a nurse and a client regarding autologous blood donations, which of the following statements, if made by the client, would indicate the need for additional education on the topic?
- A. Autologous donations require a health care provider's (HCP) order
- B. There is no age limitation for autologous blood donations
- C. I can begin autologous blood donations five weeks before my surgery date and continue up until 72 hours before surgery
- D. My autologous blood donation will be screened for infectious diseases
Correct Answer: B
Rationale: There are age limitations for autologous blood donations, typically excluding very young or elderly patients due to health risks. The other statements are correct: a provider’s order is required, donations can start five weeks and stop 72 hours before surgery, and blood is screened for infectious diseases.
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The nurse plans care for a client immediately post-operative. The nurse should initially assess the client's
- A. respiratory status
- B. tolerance to by-mouth (PO) fluids
- C. pain level
- D. ability to move the extremities
Correct Answer: A
Rationale: Respiratory status is the priority assessment post-operatively to ensure airway patency and adequate oxygenation, following the ABCs (airway, breathing, circulation) of care. Pain, fluid tolerance, and extremity movement are important but secondary to ensuring respiratory stability.
Which of the following responses should the nurse avoid when communicating with a client who has just received a poor prognosis? Select all that apply.
- A. My mother has the same thing.
- B. I'll sit with you for a while.
- C. I think you should try having surgery.
- D. Don't cry, everything is going to be okay.
- E. Do you have any questions for me right now?
Correct Answer: A,C,D
Rationale: Avoid personal anecdotes, medical advice, or minimizing emotions, as they dismiss the client’s feelings. Offering presence and open-ended questions are therapeutic.
The nurse is caring for a client with a sacral wound infected with Methicillin-resistant staphylococcus aureus. Which personal protective equipment (PPE) is necessary to care for this client? Select all that apply.
- A. Gloves
- B. N95 respirator
- C. Surgical Mask
- D. Goggles
- E. Gown
Correct Answer: A,E
Rationale: MRSA requires contact precautions, including gloves and a gown. N95 respirators, surgical masks, and goggles are not needed unless aerosol-generating procedures are performed.
The nurse is caring for a child immediately postoperative following a left ear myringotomy. The nurse should position the child
- A. left lateral recumbent
- B. prone
- C. right lateral recumbent
- D. modified trendelenburg
Correct Answer: C
Rationale: Positioning the child on the right lateral recumbent side (operative ear up) post-myringotomy facilitates drainage from the left ear and prevents pressure on the surgical site. Left lateral recumbent or prone positions could obstruct drainage, and modified Trendelenburg is not indicated.
The nurse observes a newly hired nurse apply bilateral soft-wrist restraints to a client. Which action by the newly hired nurse requires follow-up?
- A. Secures the restraint to the frame of the bed
- B. Repositions the client from semi-Fowler's to prone.
- C. Provides easy access to the quick release buckle
- D. Assesses the radial pulse every two hours
Correct Answer: B
Rationale: Positioning the client prone with wrist restraints is unsafe and increases risk of injury or respiratory compromise.