Nokea
The nurse, after administering an injection to a client, accidentally drops the syringe on the floor. Which nursing action is most appropriate in this situation?
- A. Obtain a dust pan and mop to sweep up the syringe.
- B. Call the housekeeping department to pick up the syringe.
- C. Carefully pick up the syringe from the floor and gently recap the needle.
- D. Carefully pick up the syringe from the floor and dispose of it in a sharps container.
Correct Answer: D
Rationale: Used syringes should always be placed in a sharps container immediately after use to avoid individuals from becoming injured. A syringe should not be swept up because this action poses an additional risk for getting pricked. It is not the responsibility of the housekeeping department to pick up the syringe. Syringes should never be recapped under any circumstances because of the risk of getting pricked with a contaminated needle.
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The nurse manager is observing the interaction between a new staff nurse and a client currently receiving hemodialysis. Which intervention should the nurse manager implement when the nurse and client are both drinking coffee and discussing the client's feeling about the procedure?
- A. Getting a cup of coffee and join in on the conversation
- B. Determining whether or not the client should be drinking coffee
- C. Complementing the staff nurse on the development of a good therapeutic relation
- D. Asking the staff nurse to refrain from eating and drinking in the hemodialysis area
Correct Answer: D
Rationale: The nurse manager should ask the second nurse to stop eating and drinking in the client area. A potential complication of hemodialysis is the acquisition of dialysis-associated hepatitis B. This is a concern for clients (who may carry the virus), client families (at risk from contact with the client and with environmental surfaces), and staff (who may acquire the virus from contact with the client's blood). This risk is minimized by the use of standard precautions; appropriate hand-washing and sterilization procedures; and the prohibition of eating, drinking, or other hand-to-mouth activity in the hemodialysis unit. None of the remaining options relate to management of this potential complication.
A client undergoes a subtotal thyroidectomy. The nurse ensures that which priority item is at the client's bedside upon arrival from the post-anesthesia care unit (PACU)?
- A. An apnea monitor
- B. A suction unit and oxygen
- C. A blood transfusion warmer
- D. An ampule of phytonadione
Correct Answer: B
Rationale: After thyroidectomy, respiratory distress can occur from tetany, tissue swelling, or hemorrhage. It is important to have oxygen and suction equipment readily available and in working order if such an emergency were to arise. Apnea is not a problem associated with thyroidectomy, unless the client experienced respiratory arrest. Blood transfusions can be administered without a warmer, if necessary. Phytonadione would not be administered for a client who is hemorrhaging, unless deficiencies in clotting factors warrant its administration.
The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement surgery. Which action is most appropriate for the nurse to plan to implement to protect the knee joint?
- A. Applying both ice and a compression dressing to the knee while sitting.
- B. Obtaining a walker to minimize weight-bearing by the client on the affected leg.
- C. First applying a knee immobilizer and then elevating the affect leg while sitting.
- D. Lifting the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place.
Correct Answer: C
Rationale: After a total knee replacement, as prescribed, the nurse assists the client to get out of bed on the first postoperative day after putting a knee immobilizer on the affected joint to provide stability. The leg is elevated while the client is sitting in the chair to minimize edema. A compression dressing should already be in place on the wound. Ice is not used unless prescribed. The surgeon prescribes the weight-bearing limits on the affected leg. A CPM machine is used only while the client is in bed and is initiated when prescribed.
A client with a history of silicosis is admitted diagnosed with respiratory distress and impending respiratory failure. The nurse should plan to have which intervention supplies/equipment readily available at the client's bedside to ensure a safe environment?
- A. Code cart
- B. Intubation tray
- C. Thoracentesis tray
- D. Chest tube and drainage system
Correct Answer: B
Rationale: Respiratory failure occurs when insufficient oxygen is transported to the blood or inadequate carbon dioxide is removed from the lungs and the client's compensatory mechanisms fail. The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures that an intubation tray is readily available. The other items are not needed at the client's bedside. A code cart is used for resuscitation. A thoracentesis tray contains the necessary items for performing a thoracentesis. A chest tube drainage system is used to treat a pneumothorax.
The nurse receives a client from the post-anesthesia care unit (PACU) following an above-the-knee amputation. Which should be the initial action the nurse takes to safely position the client?
- A. Elevate the foot of the bed.
- B. Put the bed in reverse Trendelenburg.
- C. Position the residual limb flat on the bed.
- D. Keep the residual limb slightly elevated with the client lying on the operative side.
Correct Answer: D
Rationale: Following an above-the-knee amputation, the residual limb is typically elevated for the first 24 hours to reduce swelling and promote venous return, which helps prevent complications such as edema. Positioning the client on the operative side with the residual limb slightly elevated (e.g., on a pillow) is the safest initial action to achieve this. Elevating the foot of the bed (option 1) may not specifically target the residual limb and could cause discomfort. Reverse Trendelenburg (option 2) elevates the head, which is not relevant to limb positioning. Keeping the limb flat (option 3) does not address swelling reduction.