Nokea
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.
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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 plans care for a client immediately post-operative. The nurse should initially assess the client's
- A. respiratory status
- B. tolerance to by-mouth (PO) fluids
- C. pain level
- D. ability to move the extremities
Correct Answer: A
Rationale: Respiratory status is the priority assessment post-operatively to ensure airway patency and adequate oxygenation, following the ABCs (airway, breathing, circulation) of care. Pain, fluid tolerance, and extremity movement are important but secondary to ensuring respiratory stability.
The nurse is caring for a client eight hours following a total thyroidectomy. The nurse plans on obtaining an order to assess the client's serum
- A. potassium level
- B. calcium level
- C. sodium level
- D. glucose level
Correct Answer: B
Rationale: Total thyroidectomy can disrupt parathyroid function, leading to hypocalcemia due to decreased parathyroid hormone. Monitoring serum calcium levels is critical to detect and manage this complication. Potassium, sodium, and glucose levels are less directly affected by thyroidectomy.
The nurse is caring for a client scheduled to receive enteral feedings via a nasogastric tube (NGT). The nurse plans on initially verifying placement of the NGT by
- A. Obtaining an abdominal x-ray (radiograph).
- B. Aspirating the gastric contents to assess the pH.
- C. Irrigating the tube with 15-20 mL of water to see if it flushes unobstructed.
- D. Inserting 20-30 mL of air into the NGT while auscultating the epigastrium.
Correct Answer: B
Rationale: Aspirating gastric contents to check pH (typically ≤5.5 for gastric placement) is the initial, non-invasive method to verify NGT placement. X-ray is definitive but not initial, irrigation checks patency not placement, and air auscultation is less reliable.
The nurse supervises unlicensed assistive personnel (UAP) assist a bed-bound client with oral hygiene. Which action by the UAP requires follow-up? Select all that apply.
- A. Raises the head of the bed (HOB) to 15 degrees
- B. Positions the toothbrush bristles at a 45-degree angle to the gum line
- C. Performs hand hygiene and applies clean gloves
- D. Removes the towel and places it in a biohazard bag
- E. Applies moisturizing lubricant to the lips after brushing and rinsing
Correct Answer: A,D
Rationale: A 15-degree HOB increases aspiration risk; it should be 30-45 degrees. Towels go in regular laundry, not biohazard. Other actions are correct.