Nokea
The nurse and two unlicensed assistive personnel (UAP) are preparing to reposition a client who requires log rolling. Which actions would be appropriate? Select all that apply.
- A. Place a small pillow between the client's knees.
- B. Places the client's arms at their side.
- C. Fanfold a drawsheet along the backside of the client.
- D. Instruct the client to laterally flex the neck during the turn.
- E. Roll the client as one unit in a smooth, continuous motion.
Correct Answer: A,B,C,E
Rationale: Pillow placement, arms at sides, drawsheet use, and rolling as a unit maintain spinal alignment. Neck flexion risks injury during log rolling.
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The nurse is caring for a postoperative client who is ordered to use an incentive spirometer. The nurse understands that this device will help prevent which complication?
- A. venous thromboembolism
- B. obstructive sleep apnea
- C. hypostatic pneumonia
- D. aspiration pneumonia
Correct Answer: C
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis, reducing the risk of hypostatic pneumonia in postoperative clients with limited mobility. It does not directly prevent venous thromboembolism, obstructive sleep apnea, or aspiration pneumonia.
The charge nurse is responding to an outbreak of influenza in a long-term care facility. To prevent the spread of this infection, the nurse recommends
- A. Having clients wear respirator masks (N95) while ambulating in the hallway.
- B. Placing air purifiers in the corridors.
- C. Obtaining prescriptions for antiviral medications for those infected.
- D. Isolating those infected using droplet precautions.
Correct Answer: C,D
Rationale: Antiviral medications and droplet precautions for infected clients control influenza spread. Client N95 masks and air purifiers are less effective.
Health History
45-year-old female admitted for laparoscopic cholecystectomy. The client recently had a weight loss of ten kilograms through dieting, and cholelithiasis was subsequently discovered. The client is alert and oriented x 4. No known drug allergies. No surgical history. The client takes levothyroxine for hypothyroidism.
• Vital Signs
Oral temperature 97 F (36° C); Pulse 90 bpm; Respirations 18; BP 110/64 mm Hg; Oxygen saturation 96% on room air.
A nurse is caring for a client in a surgery center scheduled for laparoscopic cholecystectomy.Click to specify if the nursing intervention is completed during the preoperative, intraoperative, or postoperative phase. Each intervention may be completed in more than one phase. Each row must have at least one but may have more than one response option selected.
- A. Verify the client’s name and date of birth
- B. Verify the client’s nothing-by-mouth (NPO) status
- C. Administration of prophylactic antibiotic
- D. Obtaining laboratory work such as complete blood count, clotting studies, and pregnancy test
- E. Assessment of the surgical incision site for type and amount drainage
- F. Verifying that the informed consent has been completed
- G. Confirming the correct sponge and instrument count
Correct Answer:
Rationale:
A client requests to change rooms after overhearing that their roommate is positive for the human immunodeficiency virus (HIV). The nurse should take which appropriate action?
- A. Relocate the client to a private room
- B. Ask the client to elaborate on their concern
- C. Notify the risk manager of the request
- D. Place an additional divider in-between the two beds
Correct Answer: B
Rationale: Asking the client to elaborate addresses potential misconceptions about HIV transmission, which occurs via blood or bodily fluids, not casual contact. Relocation, risk management, or dividers are unnecessary.
The nurse observes a student inserting an indwelling urinary catheter into a female client. Which action by the student requires follow-up by the nurse? The student
- A. Applies clean gloves to cleanse the perineal area with soap and water.
- B. Asks the client to bear down as the catheter is slowly inserted through the urethral meatus.
- C. Separates the labia with the fingers of the dominant hand when cleaning with antiseptic solution.
- D. Secures the catheter tubing to the inner thigh.
- E. Attaches the drainage bag to the side rails of bed.
Correct Answer: A,C,E
Rationale: Sterile gloves are required for perineal cleaning, the non-dominant hand holds the labia, and the drainage bag should be attached below the bladder level, not to side rails. Bearing down and securing to the inner thigh are correct.