Nokea
The nurse assesses a client's central venous catheter dressing, and it appears loose and wet. The nurse should take which action?
- A. Reinforce the dressing with paper tape
- B. Remove the dressing and the central vascular device
- C. Apply a clean occlusive dressing to the site
- D. Clean the site and apply a new sterile dressing
Correct Answer: D
Rationale: Cleaning the site and applying a new sterile dressing prevents infection and ensures catheter security.
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The nurse is caring for a client who underwent moderate sedation for a closed shoulder reduction. The nurse reviews the client’s clinical data. Which post-procedure data requires immediate followup?
- A. Blood Pressure
- B. Glasgow Coma Scale
- C. Respirations
- D. Temperature
Correct Answer: C
Rationale: Respiratory depression is a critical risk post-moderate sedation, so abnormal respirations require immediate follow-up. Blood pressure, Glasgow Coma Scale, and temperature are important but secondary unless specific abnormalities are noted.
The nurse has attended a conference on intraoperative nursing interventions for the older adult. which of the following statements by the nurse would indicate the need for additional teaching?
- A. Warming devices should be used to prevent the client from developing hypothermia
- B. The client's head and feet should be covered during surgery
- C. Clients should be slid, not lifted into the proper position
- D. Providing extra padding for clients with decreased peripheral circulation is important
Correct Answer: C
Rationale: Sliding clients instead of lifting can cause shear injuries, particularly in older adults with fragile skin. Warming devices, covering extremities, and extra padding are appropriate to prevent hypothermia and protect pressure points, indicating correct understanding.
The nurse is caring for a client who has generalized urticaria. Which disease transmission precautions should the nurse implement?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: D
Rationale: Generalized urticaria is typically non-infectious (e.g., allergic), requiring only standard precautions. Transmission-based precautions are unnecessary.
The nurse is developing a plan of care for a client with pertussis. It would be appropriate for the nurse to include which interventions? Select all that apply.
- A. Wear a surgical mask when working within three feet of the client
- B. Provide disposable dishes for meals
- C. Keep the client's room door closed
- D. Provide the client with a portable fan
- E. Maintain negative air pressure
- F. Apply a N95 mask to the client during transport
- G. Place the client in a room near the nurse's station
Correct Answer: A,C,F
Rationale: Pertussis requires droplet precautions: surgical mask within 3 feet, closed door, and N95 for transport. Disposable dishes, fans, and negative pressure are not needed.
The nurse has obtained a client's blood pressure. The nurse recognizes that which of the following factors may increase a client's blood pressure?
- A. Nicotine patch application
- B. Heat exhaustion
- C. Performing deep breathing exercises
- D. Hypothyroidism
Correct Answer: A
Rationale: Nicotine, a vasoconstrictor, increases blood pressure. Heat exhaustion, deep breathing, and hypothyroidism typically lower or do not affect BP acutely.