Nokea
The nurse cares for a client with a double-lumen peripherally inserted central catheter (PICC). Which of the following actions would be appropriate for the nurse to take?
- A. Assign the client to a private room.
- B. Change the dressing daily using sterile technique.
- C. Flush heparin prior to discontinuation.
- D. Aspirate each lumen for blood return and then flush.
Correct Answer: D
Rationale: Aspirating for blood return and flushing ensures PICC patency. Private rooms, daily dressing changes, and heparin flushing are not standard unless specified.
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The nurse is preparing for the first interaction with a client recently admitted to the hospital. Which of the following would help establish trust during this encounter? Select all that apply.
- A. Make sure the client's bed is set up properly ahead of time.
- B. Review the client's name, diagnosis, and anticipated length of stay before they arrive.
- C. Speak confidently and do not tell the client that one of the nurses providing care is a student nurse.
- D. Show the client how to use the bed and call light.
- E. Avoid spending too much time talking with the client.
- F. Ask about the client's expectations and concerns when taking the health history.
Correct Answer: A,B,D,F
Rationale: Preparing the environment, knowing client details, demonstrating equipment, and addressing concerns build trust. Avoiding student disclosure is deceptive, and limiting talk time hinders rapport.
The nurse is performing health screenings on a group of refugees. The nurse plans on performing which screening for this population group? Select all that apply.
- A. Hypothyroidism
- B. Attention deficit hyperactivity disorder (ADHD)
- C. Pulmonary tuberculosis
- D. Intestinal parasites
- E. Viral hepatitis
Correct Answer: C,D,E
Rationale: Refugees are at higher risk for tuberculosis, intestinal parasites, and viral hepatitis due to living conditions and exposure risks.
The nurse is caring for a child immediately postoperative following a left ear myringotomy. The nurse should position the child
- A. left lateral recumbent
- B. prone
- C. right lateral recumbent
- D. modified trendelenburg
Correct Answer: C
Rationale: Positioning the child on the right lateral recumbent side (operative ear up) post-myringotomy facilitates drainage from the left ear and prevents pressure on the surgical site. Left lateral recumbent or prone positions could obstruct drainage, and modified Trendelenburg is not indicated.
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 caring for a client who is describing pain on their hand as 'throbbing and sharp.' Which type of pain is the client experiencing based on this sensory description?
- A. Somatic pain
- B. Visceral pain
- C. Ischemic pain
- D. Neuropathic pain
Correct Answer: A
Rationale: Throbbing and sharp pain describe somatic pain, arising from skin or musculoskeletal tissue. Visceral pain is dull, ischemic pain is aching, and neuropathic pain is burning or tingling.