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The nurse is caring for a client who is two days postoperative following a right femoral popliteal bypass surgery. The client reports worsening pain, and the assessment showed swelling and ecchymosis at the incision sites. The nurse should initially
- A. Apply pressure to sites with sandbag
- B. Palpate pedal pulses
- C. Assess for signs of claudication
- D. Apply warm compress to incision sites
Correct Answer: B
Rationale: Worsening pain, swelling, and ecchymosis at the incision sites suggest possible complications such as hematoma or compromised vascular flow. Palpating pedal pulses is the priority to assess the patency of the bypass graft and ensure adequate distal perfusion. Applying pressure or warm compresses could exacerbate bleeding or swelling, and claudication assessment is less urgent than confirming vascular integrity.
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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. Immediately evacuate clients and personnel from the area.
- B. Don personal protective equipment (PPE) before cleaning up the spill.
- C. Contain the spill using non-absorbable sheets or pads.
- D. Complete an incident report.
- E. Discard all material used in cleanup in a trash bag.
- F. Implement droplet precautions after the spill has been cleaned.
Correct Answer: A,B,C,D
Rationale: Evacuation, PPE, containment, and incident reporting are standard for chemotherapy spills. Cleanup materials require biohazard disposal, not regular trash.
Your client is reluctant to take a necessary dose of narcotic analgesic for severe pain. The client states, 'I do not want to become a druggie.' How would you respond to this client's comment?
- A. That is ridiculous. Nobody gets addicted to narcotics when they do not have a prior history of drug abuse.
- B. The possible complications of unrelieved pain greatly outweigh the risk of addiction which is very low when a person has no prior history of drug abuse.
- C. A lot of people prefer to be brave and stick it out so you are not alone.
- D. You have a right to refuse any and all treatments, so just do without it.
Correct Answer: B
Rationale: Addressing pain complications and reassuring low addiction risk educates and encourages treatment. Dismissing concerns, normalizing endurance, or supporting refusal are non-therapeutic.
The nurse is caring for assigned clients. Which essential infection control measure should the nurse take?
- A. Perform hand hygiene before, after, and between providing direct client care
- B. Wear gloves while providing client care
- C. Cleanse equipment such as thermometers or stethoscopes between client care
- D. Maintain a distance of 3 feet away from clients who are coughing
Correct Answer: A
Rationale: Hand hygiene is the most essential infection control measure to prevent pathogen transmission.
A nurse prepares a client for computed tomography (CT) scan with intravenous (IV) iodinated contrast. The nurse should take which action?
- A. Ask the client if they are allergic to shellfish
- B. Insert a 20-gauge peripheral vascular access device
- C. Obtain capillary blood glucose (CBG)
- D. Instruct the client to decrease their fluids after the procedure
Correct Answer: A
Rationale: Iodinated contrast carries a risk of allergic reactions, and a history of shellfish allergy may indicate iodine sensitivity, requiring further evaluation. A 20-gauge may be appropriate but isn’t the priority, CBG is irrelevant, and fluid restriction is incorrect.
The nurse is preparing to administer intravenous chemotherapy to a client with cancer. While preparing the infusion in the client's room, the bag rips and leaks on the floor. The nurse should initially?
- A. obtain a chemotherapy spill kit.
- B. evacuate the client from the area.
- C. complete an incident report.
- D. request guidance from the pharmacy.
Correct Answer: A
Rationale: A chemotherapy spill kit is the initial action to safely clean hazardous material.