Nokea
The nurse is assessing a client who just returned from surgery. The nurse checks preoperative vital signs at 0830 to compare them with the current vital signs at 1030 . What action should the nurse take?
- A. Assess the surgical wound
- B. Collect blood cultures
- C. Administer oxygen at 2 L/minute
- D. Encourage by-mouth (PO) fluids
Correct Answer: C
Rationale: Changes in vital signs post-surgery may indicate respiratory or circulatory compromise. Administering oxygen at 2 L/minute is a prudent initial action to support oxygenation while further assessment occurs. Wound assessment, blood cultures, or fluids require specific clinical indications.
You may also like to solve these questions
The nurse needs to assess the use of complementary and alternative medicine (CAM) because:
- A. Patients should be warned that most CAM therapies are potentially dangerous
- B. Additional treatment may not be needed if the patient is using CAM
- C. CAM therapy could interact with prescription and over-the-counter medications
- D. Most CAM therapies are essentially ineffective
Correct Answer: C
Rationale: CAM therapies can interact with medications, affecting efficacy or safety. Not all CAM is dangerous, ineffective, or a replacement for conventional treatment.
The nurse is recommending respite care to a client and their caregiver. The nurse understands that this care is designed to
- A. Improve the quality of life of clients and families who are experiencing problems related to life-threatening illnesses.
- B. Provide a variety of health and social services to specific patient populations.
- C. Have clients live with comfort, independence, and dignity while easing the pain of terminal illness.
- D. Offers short-term relief by providing caregivers who support the ill, disabled, or frail older adults time to relax.
Correct Answer: D
Rationale: Respite care provides temporary relief for caregivers, allowing them rest. Other options describe palliative or comprehensive care services.
The nurse is observing a student collect vital signs on a client. Which action by the student requires the nurse to intervene? Select all that apply.
- A. Obtains the blood pressure with a cuff bladder width of at least 40% of arm circumference.
- B. Places the BP cuff over the client's clothing garment.
- C. Requests the client remove their hearing aid before obtaining a tympanic temperature.
- D. Assesses the client's respirations after obtaining the pulse rate.
- E. Obtains blood pressure by placing the client's upper extremity at the level of their heart.
- F. Places the pulse oximeter probe on the client's finger that has edema.
Correct Answer: B,F
Rationale: Placing the BP cuff over clothing and using an edematous finger for pulse oximetry can yield inaccurate readings. Other actions are correct.
The nurse is teaching a client how to ambulate using a walker. The nurse should
- A. Have the client stand on the side of the walker to have them properly fitted.
- B. Position the top of the walker so it lines up with the client's wrist crease.
- C. Ensure the client's feet are close together while holding onto the walker handgrips.
- D. Instruct the client to lean forward over the walker so they do not lose balance.
- G. None
Correct Answer: B
Rationale: The walker’s top aligns with the wrist crease for proper height. Standing on the side, close feet, or leaning forward are unsafe or incorrect for fitting or use.
The nurse in the emergency department (ED) is caring for a child with erythema infectiosum (Fifth disease). Which transmission-based precautions should the nurse implement?
- A. Standard
- B. Droplet
- C. Contact
- D. Airborne
Correct Answer: A
Rationale: Erythema infectiosum is typically non-infectious once the rash appears, requiring only standard precautions.