Nokea
The nurse is assisting a client with the use of a fracture bedpan. Which action should the nurse take?
- A. Position the client prone while placing the bedpan.
- B. Raise the head of the bed to 30 degrees.
- C. Place the open rim of the bedpan toward the head of the bed.
- D. Lower all of the side rails
Correct Answer: B
Rationale: Raising the head of the bed to 30 degrees facilitates client comfort and proper positioning for a fracture bedpan. Prone positioning is incorrect, the open rim faces the foot of the bed, and lowering all side rails is unsafe.
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The nurse is preparing to prime a new line of IV tubing. The nurse understands that priming intravenous tubing is crucial because it prevents which treatment complication?
- A. Medication toxicity
- B. Infiltration
- C. Air embolism
- D. Extravasation
Correct Answer: C
Rationale: Priming IV tubing removes air, preventing air embolism, a potentially fatal complication. Other complications are unrelated to priming.
The charge nurse is making room assignments for assigned clients. The charge nurse has one private room remaining, the nurse should assign the private room to the client admitted with
- A. Epilepsy, who had a tonic-clonic seizure two hours ago.
- B. An indwelling urinary catheter and has proteus mirabilis in the urine.
- C. Viral meningitis and has a fever.
- D. Clostridium difficile who is incontinent of stool.
Correct Answer: D
Rationale: C. difficile with incontinence requires contact precautions, necessitating a private room to prevent spread. Other conditions do not require isolation.
A client requests to change rooms after overhearing that their roommate is positive for the human immunodeficiency virus (HIV). The nurse should take which appropriate action?
- A. Relocate the client to a private room
- B. Ask the client to elaborate on their concern
- C. Notify the risk manager of the request
- D. Place an additional divider in-between the two beds
Correct Answer: B
Rationale: Asking the client to elaborate addresses potential misconceptions about HIV transmission, which occurs via blood or bodily fluids, not casual contact. Relocation, risk management, or dividers are unnecessary.
The nurse is caring for a postoperative client who is ordered to use an incentive spirometer. The nurse understands that this device will help prevent which complication?
- A. venous thromboembolism
- B. obstructive sleep apnea
- C. hypostatic pneumonia
- D. aspiration pneumonia
Correct Answer: C
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis, reducing the risk of hypostatic pneumonia in postoperative clients with limited mobility. It does not directly prevent venous thromboembolism, obstructive sleep apnea, or aspiration pneumonia.
The nurse cares for a client scheduled for spinal surgery in one hour. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe
- A. gentamicin
- B. enoxaparin
- C. hydromorphone
- D. cyclobenzaprine
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, is commonly prescribed preoperatively for spinal surgery to prevent venous thromboembolism due to prolonged immobility. Gentamicin is an antibiotic, hydromorphone is for pain, and cyclobenzaprine is a muscle relaxant, none of which are typically prioritized preoperatively for this purpose.