Nokea
The nurse in the postanesthesia care unit (PACU) cares for a client who had an appendectomy. Which of the following client assessments warrants immediate follow-up?
- A. has breath sounds that are high-pitched and crowing
- B. reports incisional pain at a level of '5' on a scale of 0 (no pain) to 10 (severe pain)
- C. has a capillary blood glucose of 115 mg/dL [70-110 mg/dL]
- D. reports persistent nausea following the administration of an anti-emetic
Correct Answer: A
Rationale: High-pitched, crowing breath sounds suggest airway obstruction or stridor, a critical finding requiring immediate intervention to ensure airway patency. Moderate pain, slightly elevated glucose, and nausea are less urgent.
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The nurse is preparing to obtain a capillary blood glucose from a client. Place the following actions in the order in which they should be performed, starting from first to last.
- A. Hold the gauze on the client's finger after the specimen has been obtained.
- B. Turn the finger down to promote blood flow with gravity.
- C. Insert strip into monitor.
- D. Prick the side of the finger using the lancet.
- E. Verify and confirm that the code strip corresponds to the meter code.
- F. Disinfect the client's finger with an alcohol swab and allow it to dry.
- G. Read the client's blood glucose level on the monitor.
Correct Answer: E,F,C,D,B,A,G
Rationale: The correct order is: verify strip code (E), disinfect finger (F), insert strip (C), prick finger (D), promote blood flow (B), collect sample and apply gauze (A), read result (G). This ensures accuracy and safety.
The nurse is teaching a group of students on incident reports. Which of the following situations would require an incident report? Select all that apply.
- A. Requesting to view their medical record.
- B. Complaining about poor care from a nurse.
- C. Leaving against medical advice (AMA).
- D. Requesting an increase in pain medication.
- E. Threatening a nurse with bodily harm.
Correct Answer: B,C,E
Rationale: Complaints about care, AMA, and threats require incident reports to document potential risks or issues. Viewing records and requesting medication changes do not.
The nurse is caring for a client who has been physically violent towards staff. The nurse prepares to restrain the client using
- A. soft wrist restraints.
- B. mitten restraints.
- C. elbow restraints.
- D. waist belt restraint.
Correct Answer: A
Rationale: Soft wrist restraints are appropriate for preventing harm in violent clients while allowing some movement. Other options are less suitable.
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. A pulse of 5 is abnormally low for a 5-year-old (normal 70-120). BP 110/60, RR 24, and temperature 37°C are within normal limits. None Regular The correct answer is A. Rationale: Pulse 5 is bradycardic for a child.
- 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: These actions by the UAP require follow-up. The head of the bed should ideally be elevated to between 30-45 degrees to facilitate effective oral hygiene and reduce the risk of aspiration. A lower angle may make it more difficult for the client to swallow properly and increase the risk of choking. Placing a towel used for oral hygiene in a biohazard bag is unnecessary unless it is saturated with blood or other potentially infectious materials. The towel used to protect the client's clothing during oral hygiene is typically considered regular linen and should be placed in a linen bag for laundering. Using a biohazard bag for non-contaminated items increases waste and may lead to confusion in waste management procedures.
A client is rushed to the emergency department after exposure to radioactive materials in a workplace accident. The client's supervisor phoned ahead and informed the charge nurse of the chemical with which the client came in contact. What should be the initial action of the nurse?
- A. Remove all the client's clothing and decontaminate the client.
- B. Ask the client what happened during the accident.
- C. Decontaminate the room where the client was staying.
- D. Save the clothing for analysis.
Correct Answer: A
Rationale: Removing clothing and decontaminating the client is the initial action to minimize radiation exposure.