Nokea
The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
- A. Discomfort while speaking
- B. Frequent swallowing
- C. Drowsiness
- D. Pain with occasional coughing
Correct Answer: B
Rationale: Frequent swallowing in a post-tonsillectomy child may indicate bleeding in the throat, as the child swallows blood, requiring immediate follow-up to prevent hemorrhage. Discomfort, drowsiness, and pain with coughing are expected findings and less urgent.
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The nurse is preparing to obtain capillary blood glucose (CBG) for a client with diabetes mellitus. The nurse should take which action? Select all that apply.
- A. Apply gloves for this procedure
- B. Have the client wash their hands with soap and water prior to blood collection
- C. Collect the second blood drop on the test strip
- D. Prick the central part of the finger for the sample
- E. Clean and disinfect the glucometer in between uses
Correct Answer: A,B,C,E
Rationale: Gloves protect against blood exposure, hand washing ensures a clean sample, the second drop avoids contamination, and disinfecting the glucometer prevents infection. Pricking the central finger part is less preferred than the side.
The nurse is conducting a staff education program on managing chemotherapy spills. Which actions should the nurse recommend be taken in the event of a chemotherapy spill? Select all that apply.
- A. Contain the spill using plastic-backed absorbent sheets or spill pads.
- B. Wear sterile gloves when cleaning the spill.
- C. Immediately remove any contaminated clothing and wash the affected skin with soap and water.
- D. Research the appropriate cleaning agent based on the spilled drug.
- E. Leave the spill area unattended until a supervisor arrives.
- F. Implement airborne precautions after the spill has been cleaned.
Correct Answer: A,C
Rationale: Containing the spill and decontaminating skin/clothes are critical. Sterile gloves are unnecessary, researching during a spill delays action, leaving unattended is unsafe, and airborne precautions are irrelevant.
The nurse assists a client with left-sided weakness. Which of the following actions should the nurse perform when assisting this client in ambulating with a cane? Select all that apply.
- A. Place a gait belt around the client's waist.
- B. Stand on the client's left side during ambulation.
- C. Instruct the client to put the cane in the left hand.
- D. Measure the cane from the client's wrist crease.
- E. Instruct the client to put the cane in the right hand.
- F. Instruct the client to look down while ambulating.
Correct Answer: A,B,E
Rationale: A gait belt ensures safety, standing on the weaker side provides support, and the cane in the right hand aids balance. Cane height is measured to the greater trochanter, and looking down risks falls.
The nurse is reviewing a newly hired nurse's understanding of sterile technique. Which statement, if made by the newly hired nurse, would indicate effective understanding? Select all that apply.
- A. I should open sterile packages away from my body.
- B. If the sterile field gets contaminated, I should dispose of everything and start over.
- C. One inch (2.5 cm) border around a sterile drape can be touched with clean fingers.
- D. I should apply sterile gloves on my non-dominant hand first.
- E. An object placed below my waist is considered contaminated.
Correct Answer: A,B,D,E
Rationale: Opening packages away, restarting after contamination, applying gloves correctly, and recognizing below-waist contamination are correct. The 1-inch border is non-sterile and should not be touched.
The patient who is two days postoperative cesarean section complains of right shoulder discomfort. Which action should the nurse take first?
- A. Administer PRN analgesic.
- B. Obtain STAT EKG.
- C. Encourage ambulation.
- D. Discuss the pain with the patient.
Correct Answer: D
Rationale: Discussing the pain assesses its nature, as shoulder discomfort post-cesarean may indicate referred pain from diaphragmatic irritation. Analgesics, EKG, or ambulation are premature without assessment.