Nokea
The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to
- A. wrap the leg with elastic bandages
- B. apply pressure at the bleeding site
- C. reinforce the dressing and elevate the leg
- D. remove the dressings and re-dress the incision
Correct Answer: C
Rationale: The interventions that must be taken are: reinforce the dressing, elevate the extremity to decrease blood flow into the extremity and thus decrease bleeding, and call the provider immediately. This is an emergency post-surgical situation.
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The nurse is preparing to change the soiled bed linens of the client with acute diarrhea of unknown origin. Which interventions should the nurse implement? Select all that apply.
- A. Wear a mask while changing the soiled linens
- B. Wear gown and gloves while in the room
- C. Use alcohol-based hand wash before and after care
- D. Request that the HCP prescribe a stool culture
- E. Post an enteric precaution sign outside the room
Correct Answer: B,D,E
Rationale: B: Gown and gloves protect against potential infectious stool. D: A stool culture identifies the cause. E: Enteric precautions prevent transmission. A: Masks are unnecessary for non-airborne pathogens. C: Soap and water are needed for possible C. difficile.
The nurse observes that the NA enters the client room, provides direct care, and then exits without performing any hand hygiene. Which is the appropriate initial action of the nurse?
- A. Inform the nurse manager about the NA's performance.
- B. File a facility incident or variance report immediately.
- C. Talk to the NA immediately about performing hand hygiene.
- D. Tell the client to remind all staff to perform hand hygiene.
Correct Answer: C
Rationale: C: Immediate discussion with the NA addresses the issue directly and promotes compliance. A, B: These are secondary actions. D: Client involvement is inappropriate.
A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce?
- A. It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum)
- B. It is critical to report promptly to your health care provider any findings of peptic ulcers
- C. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors
- D. With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine
Correct Answer: B
Rationale: It is critical to report promptly to your health care provider any findings of peptic ulcers. Such findings include night-time awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite.
The clinic nurse encounters the client who has a congested cough and rhinorrhea. The nurse follows droplet precautions/cough protocol by taking which action? Select all that apply.
- A. Offering the client sterile disposable tissues
- B. Wearing a mask while examining the client
- C. Offering the client water to drink while waiting
- D. Teaching how to cover the mouth when coughing
- E. Performing hand hygiene before and after client contact
- F. Separating the client by at least 3 feet from others in the area
Correct Answer: B,D,E,F
Rationale: B: A mask is required during examination to prevent droplet transmission. D: Teaching cough etiquette reduces spread. E: Hand hygiene prevents pathogen transmission. F: Maintaining 3 feet distance reduces droplet spread. A: Sterile tissues are unnecessary. C: Water does not limit transmission.
The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?
- A. We will call the health care provider if the child develops acne.'
- B. Our child should brush and floss carefully after every meal.'
- C. We will skip the next dose if vomiting or fever occur.'
- D. When our child is seizure-free for 6 months, we can stop the medication.'
Correct Answer: B
Rationale: Our child should brush and floss carefully after every meal.' Phenytoin causes lymphoid hyperplasia that is most noticeable in the gums. Frequent gum massage and careful attention to good oral hygiene may reduce the gingival hyperplasia.