Nokea
The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?
- A. Check the client's carotid pulse
- B. Encourage the client to get to the toilet
- C. In a loud voice, call for help
- D. Gently lower the client to the floor
Correct Answer: D
Rationale: The priority action for the nurse is to gently lower the client to the floor (Option D). This action is crucial to prevent injury to both the client and the nurse. Lowering the client to the floor should be done when the client is unable to support his own weight, ensuring a safe position to prevent falls. Checking the client's carotid pulse (Option A) is important, but it should be performed after ensuring the client's safety. Encouraging the client to get to the toilet (Option B) is impractical as the client is already falling. Calling for help in a loud voice (Option C) may cause chaos and alarm other clients, making it a less suitable immediate action in this scenario.
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By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?
- A. Mode of transmission
- B. Portal of entry
- C. Reservoir
- D. Portal of exit
Correct Answer: A
Rationale: When the nurse rolls contaminated gloves inside-out, they are manipulating the mode of transmission in the chain of infection. The gloves, which are contaminated, act as a vehicle for transferring pathogens from the reservoir's portal of exit to a potential portal of entry. Choices B, C, and D are incorrect because the action of rolling contaminated gloves does not directly relate to the portal of entry, reservoir, or portal of exit in the chain of infection.
A client scheduled for pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. Which therapeutic response should the nurse make to the client to provide reassurance?
- A. The procedure is somewhat painful, but there is minimal exposure to radiation.'
- B. Discomfort may occur with needle insertion, and there is minimal exposure to radiation.'
- C. There is very mild pain throughout the procedure, and the exposure to radiation is negligible.'
- D. There is usually no pain, although a moderate amount of radiation must be used to get accurate results.'
Correct Answer: B
Rationale: Pulmonary angiography involves minimal exposure to radiation. The procedure is painless, although the client may feel discomfort with insertion of the needle for the catheter that is used for dye injection. This information supports the fact that the other options are incorrect.
A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide?
- A. Orange juice has vitamin C that deters bacterial growth.
- B. Apple juice is the most useful in acidifying the urine.
- C. Cranberry juice stops pathogens' adherence to the bladder.
- D. Grapefruit juice increases absorption of most antibiotics.
Correct Answer: C
Rationale: The correct answer is 'Cranberry juice stops pathogens' adherence to the bladder.' Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. This helps prevent UTIs. Options A, B, and D are incorrect because orange juice with vitamin C, apple juice for urine acidification, and grapefruit juice for antibiotic absorption do not have the same proven effectiveness in preventing UTIs as cranberry juice does.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
- A. Apply a warm compress proximal to the site.
- B. Check for kinks in the tubing and raise the IV pole.
- C. Adjust the tape that stabilizes the needle.
- D. Change the IV solution bag.
Correct Answer: B
Rationale: When a nurse assesses a slowed IV rate by gravity with a healthy venous access site in a 2-year-old admitted for dehydration, the next step would be to check for kinks in the tubing and raise the IV pole. This action ensures that the IV fluid can flow freely and reach the patient at the correct rate. Applying a warm compress proximal to the site (Choice A) is not indicated in this situation as it does not address the underlying issue of a slowed IV rate due to mechanical factors. Adjusting the tape that stabilizes the needle (Choice C) or changing the IV solution bag (Choice D) are not the priority actions in this case. These choices do not address the issue of a slowed IV rate caused by kinks in the tubing or the height of the IV pole, which are more likely reasons for the problem observed.
An 8-year-old is admitted to the hospital after being sexually abused by an adult family member. The child is withdrawn and appears frightened. Which describes the best plan for the initial nursing encounter to convey concern and support?
- A. Introduce self and explain to the child that she or he is safe now here in the hospital.
- B. Introduce self and tell the child that you would like to sit with the child for a little while.
- C. Introduce self and then ask the child to express how she or he feels about the events leading up to this hospital admission.
- D. Introduce self, explain your role, and ask the child to act out the sexual encounter with the abuser with the use of art therapy.
Correct Answer: B
Rationale: Victims of sexual abuse may exhibit fear and anxiety regarding what has just occurred. In addition, they may fear that the abuse could be repeated. When initiating contact with a child victim of sexual abuse who demonstrates a fear of others, it is best to convey a willingness to spend time and move slowly to initiate activities that may be perceived as threatening. After a rapport is established, the nurse may explore the child's feelings or use various therapeutic modalities to encourage the recounting of the sexual encounter. Option 2 conveys a plan for an initial encounter that establishes trust by sitting with the child in a nonthreatening atmosphere. Option 1 does not convey concern and support by the nurse. Options 3 and 4 may be implemented after trust and rapport are established.