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.
You may also like to solve these questions
The occupational health nurse is conducting an in-service on reducing back injuries in the workplace. It would be correct for the nurse to identify that the most common location of back injuries is in the
- A. Cervical spine.
- B. Lumbar spine.
- C. Thoracic spine.
- D. Pelvis.
Correct Answer: B
Rationale: The lumbar spine is the most common site for back injuries due to its weight-bearing role and flexibility. Other areas are less frequently injured.
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 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.
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 participating in a fall and injury reduction committee to reduce falls in the inpatient environment. Which risk factors in the inpatient environment can be modified through this committee? Select all that apply.
- A. The lighting in the client rooms
- B. Staffing levels
- C. Communication failures
- D. Inadequate client assessment
- E. The prescribing of antihypertensive medications
Correct Answer: A,B,C,D
Rationale: Lighting, staffing, communication, and assessments are modifiable environmental factors. Medication prescribing is a clinical decision.