Nokea
A nurse manager is providing an in-service to a group of newly licensed nurses about the use of personal protective equipment. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?
- A. I should wear a gown to remove linens from a client's be '
- B. Sterile gloves are required when administering an IM injection.'
- C. I should wear goggles when irrigating a woun '
- D. I should use both hands to recap a needle.'
Correct Answer: C
Rationale: The correct answer is C: "I should wear goggles when irrigating a wound." This indicates an understanding of the teaching as goggles protect the eyes from splashes and sprays. Wearing goggles during wound irrigation helps prevent potential eye exposure to contaminated fluids, reducing the risk of infection.
Choice A is incorrect because wearing a gown to remove linens is unnecessary for personal protective equipment during this task. Choice B is incorrect as sterile gloves are required for clean procedures like wound care, not for administering IM injections. Choice D is incorrect because using both hands to recap a needle increases the risk of needle-stick injuries.
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A nurse is caring for a client receiving TPN. Which of the following actions should the
nurse take? For each potential nursing intervention, click to specify if the potential intervention
is anticipated, nonessential, or contraindicated for the client.
- A. Request a prescription for insulin
- B. Request for an antibitic to be administered
- C. Decrease the client's oxygen to 1.5 L/min via nasal canula
- D. Have 3 nurses verify the TPN solution prescription
- F. Notify the provider to increase TPN rate/hr
Correct Answer: A,B,C,D
Rationale: [
Anticipated: Request a prescription for insulin, Request for an antibiotic to be administered, Decrease the client's oxygen to 1.5 L/min via nasal cannula, Have 3 nurses verify the TPN solution prescription.
Rationale: A client on TPN may require insulin for glycemic control, antibiotics for infection management, oxygen adjustment for respiratory support, and verification of TPN solution to prevent errors.
Non-essential/Contraindicated: Not applicable as all options are essential in the care of a client receiving TPN.]
A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?
- A. Remove one of the weights.
- B. Tie knots in the ropes near the pulleys to shorten them.
- C. Increase the elevation of the affected extremity.
- D. Reapply the weights to ensure proper traction.
Correct Answer: D
Rationale: The correct answer is D: Reapply the weights to ensure proper traction. When the weights are resting on the floor, it means that there is no longer effective traction on the affected limb. To maintain proper skeletal traction, the weights should be suspended freely in the air. By reapplying the weights and ensuring they are hanging freely, the nurse can restore the necessary traction force to immobilize the fractured bone and facilitate healing. Removing a weight (choice A) may compromise the traction. Tying knots in the ropes (choice B) may alter the mechanics of the traction system. Increasing the elevation of the extremity (choice C) does not address the issue of the weights resting on the floor.
A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following medications should the nurse instruct the client to avoid? (Select all that apply)
- A. Ferrous sulfate
- B. Echinacea
- C. Aspirin
- D. Dextromethorphan
- E. Naproxen
Correct Answer: C, E
Rationale: The correct choices are C (Aspirin) and E (Naproxen) because they both increase the risk of bleeding when used with warfarin, an anticoagulant. Aspirin and Naproxen are nonsteroidal anti-inflammatory drugs (NSAIDs) that can further inhibit platelet function and prolong bleeding time, leading to potential complications. Ferrous sulfate (A) is an iron supplement and does not directly interact with warfarin. Echinacea (B) is an herbal supplement with minimal known interactions with warfarin. Dextromethorphan (D) is a cough suppressant and does not impact warfarin's anticoagulant effects. In summary, the nurse should instruct the client to avoid Aspirin and Naproxen to prevent potential bleeding complications when taking warfarin.
A nurse is preparing to administer potassium chloride 10 mEq IV over 1 hr to a client. Available is potassium chloride 10 mEq in 100 mL of 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number.)
- A. 50 mL/hr
- B. 75 mL/hr
- C. 100 mL/hr
- D. 125 mL/hr
Correct Answer: C
Rationale: To determine the infusion rate, we first calculate the total volume of the solution to be infused (100 mL) over the total time (1 hr). Therefore, the infusion pump should be set to deliver 100 mL/hr (Choice C). This ensures the correct administration of potassium chloride 10 mEq IV over 1 hr. Choices A, B, and D are incorrect because they do not accurately reflect the infusion rate required for the specified dose and time frame.
A nurse is assessing a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
- A. Maintain abduction of the affected extremity.
- B. Position the client in high Fowler’s position.
- C. Encourage the client to cross their legs at the ankles.
- D. Have the client bend forward at the waist while sitting.
Correct Answer: A
Rationale: The correct answer is A: Maintain abduction of the affected extremity. After a total hip arthroplasty, maintaining abduction of the affected extremity helps prevent dislocation of the hip prosthesis. This position helps stabilize the hip joint and reduces the risk of complications. Option B (Position the client in high Fowler's position) is incorrect as it does not directly address the postoperative care specific to a total hip arthroplasty. Option C (Encourage the client to cross their legs at the ankles) is incorrect because crossing legs can create pressure on the hip joint and increase the risk of dislocation. Option D (Have the client bend forward at the waist while sitting) is incorrect as this could also increase the risk of hip dislocation.