Nokea
The nurse is caring for a client admitted with severe pre-eclampsia. It would be essential for the nurse to have which of the following items at the bedside?
- A. One liter of 0.9% saline
- B. Sterile gloves
- C. Portable ultrasound
- D. Suction equipment
Correct Answer: D
Rationale: Severe pre-eclampsia increases seizure risk (eclampsia), requiring suction equipment at the bedside to manage airway secretions during a seizure. Saline, gloves, and ultrasound are not immediate priorities for seizure management.
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The nurse is preparing to obtain a wound culture on an infected leg ulcer. Before swabbing the wound to obtain the culture, the nurse should
- A. Clean the wound with sterile saline.
- B. Pat dry the wound with gauze.
- C. Irrigate the wound with hydrogen peroxide.
- D. Don sterile gloves
Correct Answer: A
Rationale: Cleaning with sterile saline removes debris, ensuring an accurate culture. Drying, using peroxide, or sterile gloves (clean gloves suffice) are not appropriate.
The nurse performs a home safety survey for an older adult. Click to specify the findings that require intervention by the nurse.
- A. Scatter rugs at the end of the stairs
- B. Smoke detector present without a battery
- C. Stairs present with sturdy hand rails
- D. New light fixtures installed and connected in a grounded electrical outlet
- E. Extension cord covered with an anti-skid area rug
- F. Unlabeled household chemicals under the sink
- G. Fire extinguisher present 30 feet from the stove
Correct Answer: A,B,E
Rationale: Scatter rugs and extension cords pose trip hazards, and a non-functional smoke detector is a fire risk. Unlabeled chemicals risk poisoning, requiring intervention.
The nurse supervises a student nurse preparing a client for a magnetic resonance imaging (MRI) test. Which of the following actions by the student nurse would require follow-up by the nurse? The student
- A. Asks the client if they have claustrophobia.
- B. Instructs the client to apply earplugs before the exam.
- C. Moves the nitroglycerin patch from the torso to the back.
- D. Tells the client that they will not have any exposure to radiation.
Correct Answer: C
Rationale: Moving a nitroglycerin patch can disrupt medication delivery and is unnecessary for MRI. Asking about claustrophobia, using earplugs, and confirming no radiation exposure are correct.
The nurse performs a home safety survey for an individual with epilepsy. Click to specify the findings that require intervention by the nurse
- A. Multiple glass tables in the living room
- B. Multiple feather pillows present on the bed
- C. Padded covers on the edges of countertops
- D. Wall-to-wall carpeting was removed and replaced with scattered rugs on hardwood flooring
- E. Kitchen knives were readily accessible
- F. Client reports using the microwave instead of the stove
- G. Locks on the bathroom door
Correct Answer: A,D,E,G
Rationale: Glass tables, scattered rugs, accessible knives, and bathroom locks pose injury risks during seizures, requiring intervention.
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.