Nokea
Prior to a client being transported for a chest x-ray, what should a healthcare professional do first?
- A. Identify the client using two identifiers
- B. Confirm the client's fasting status
- C. Check the client's allergies to contrast media
- D. Explain the procedure to the client
Correct Answer: A
Rationale: Identifying the client using two identifiers is the crucial first step to ensure correct patient identification before any procedure. This process helps prevent errors and ensures that the right procedure is performed on the right patient. Confirming the client's identity is the top priority before addressing other aspects such as fasting status, allergies, or explaining the procedure. While confirming fasting status and checking for allergies are important, they are secondary to confirming the client's identity. Explaining the procedure to the client is also essential but should occur after ensuring proper identification.
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The LPN/LVN observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?
- A. Observe the appearance of the skin under the ice pack.
- B. Instruct the client regarding the importance of the covering.
- C. Reapply the covering after filling it with fresh ice.
- D. Ask the client how long the ice pack was applied to the skin.
Correct Answer: A
Rationale: The correct first action for the nurse to take when a client removes the covering from an ice pack is to observe the appearance of the skin under the ice pack. This assessment is crucial to check for any skin damage or adverse reactions resulting from direct contact with the ice pack. Instructing the client about the importance of the covering (Choice B) can follow the skin assessment. Reapplying the covering (Choice C) before skin assessment may potentially cause harm. Asking the client about the duration of ice application (Choice D) is not the immediate priority; ensuring skin integrity is the primary concern.
When a nurse instructs a client with hearing loss about cleaning their new hearing aids, which statement indicates that the client understands the instructions?
- A. I use a damp cloth to clean the outside part of my hearing aids.
- B. I clean my hearing aids' ear molds with rubbing alcohol.
- C. I always keep the volume of my hearing aids turned up for better hearing.
- D. I remove the batteries from my hearing aids when not in use at night.
Correct Answer: A
Rationale: The correct answer is A because cleaning the outside part of hearing aids with a damp cloth is an appropriate method. Rubbing alcohol can damage ear molds, so choice B is incorrect. Keeping the volume of hearing aids turned up high may lead to discomfort, making choice C incorrect. Removing batteries when not in use at night is good practice for battery life, but it does not directly relate to understanding cleaning instructions, so choice D is less relevant in this context.
A client in a provider's office tells the nurse that, 'I fast for several days each week to help control my weight.' The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that result from fasting puts her at risk for medication toxicity?
- A. Increasing the metabolism of the medications over time
- B. Increasing the protein-binding response
- C. Increasing medications' transit time through the intestines
- D. Decreasing the excretion of medications
Correct Answer: B
Rationale: Fasting can lead to an increased protein-binding response of medications. This can result in a higher concentration of bound medications in the bloodstream, potentially causing toxicity as the medications may not be readily available for metabolism or excretion. Choice A is incorrect because fasting typically doesn't increase medication metabolism. Choice C is incorrect as fasting usually decreases transit time through the intestines. Choice D is incorrect since fasting generally does not decrease medication excretion.
Postoperatively, signs of hemorrhagic shock are observed. The nurse notifies the surgeon, who instructs to continue monitoring vitals every 15 minutes and report back in one hour. What should the nurse do next?
- A. Notify the nurse manager
- B. Continue monitoring as instructed
- C. Administer IV fluids as per protocol
- D. Prepare for immediate transfer to the ICU
Correct Answer: B
Rationale: The correct answer is to continue monitoring the patient as instructed. This is crucial to assess the patient's condition and response to initial interventions. Administering IV fluids or preparing for transfer to the ICU should only be done based on further assessment or explicit orders from the healthcare provider. Notifying the nurse manager, as suggested in choice A, without further assessment or intervention could delay immediate patient care and management.
A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?
- A. ''Incident report completed.''
- B. ''Client climbed over the bedrails.''
- C. ''Client found lying on the floor.''
- D. ''Client was trying to get out of bed.''
Correct Answer: C
Rationale: The correct answer is C: ''Client found lying on the floor.'' In this situation, the nurse should document factual, objective information without making assumptions. Stating that the client was found lying on the floor directly reflects what was observed. Choice A, ''Incident report completed,'' is not a statement about the incident itself and does not provide relevant information. Choice B, ''Client climbed over the bedrails,'' introduces unnecessary speculation and assumption which should be avoided when documenting incidents. Choice D, ''Client was trying to get out of bed,'' focuses on the client's behavior rather than the objective observation of the client's position when found.