Nokea
The nurse is caring for a client with a port. Which of the following actions would be appropriate to take? Select all that apply.
- A. Access the port using sterile technique.
- B. Flush the port with heparin prior to de-access.
- C. Access the port using a 16-gauge catheter.
- D. Have the client wear a mask during the dressing change.
- E. Aspirate for blood return prior to medication administration.
Correct Answer: A,B,E
Rationale: Sterile technique, heparin flushing, and aspirating for blood return are standard for port care. A 16-gauge catheter is too large, and a client mask is unnecessary.
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The nurse assesses a client who requires bilateral wrist restraints for agitation and hostility toward staff. When performing follow-up assessments, what data is necessary for the nurse to obtain? Select all that apply.
- A. previous restraint use
- B. skin integrity
- C. behavioral status
- D. vital signs
- E. urinary continence
Correct Answer: B,C,D
Rationale: Skin integrity, behavioral status, and vital signs must be assessed regularly to ensure safety, monitor for complications, and evaluate the ongoing need for restraints.
The nurse is caring for a child with varicella zoster. The nurse should implement which transmission-based precautions?
- A. Droplet precautions
- B. Airborne and contact precautions
- C. Contact and droplet precautions
- D. Contact precautions
Correct Answer: B
Rationale: Varicella zoster requires airborne and contact precautions due to its transmission via respiratory droplets and direct contact. Other options are insufficient.
Nurses’ Notes
1930 – Assessment completed
Peripheral pulses were all palpable. S1/S2 heart tones auscultated. No peripheral edema.
Lung sounds were clear in all fields. Client denied any cough or dyspnea. Respirations were regular and unlabored.
Bowel sounds were active in all quadrants, with no abdominal distention noted. Client only reports nausea after her prescribed acetaminophen-oxycodone.
Surgical incisions appeared approximated, reddened, and the surrounding area was hot to touch. Small amount of foul-smelling, purulent type of drainage was noted. The gauze dressing was changed, and a new gauze dressing was applied.
Client reported intermittent incisional pain of 3/10 described as ‘sore’. Vital Signs: Oral Temperature 100.4° F (38° C)
Pulse 93/minute
Respirations 18/minute
Blood pressure 111/69 mm Hg
O2 saturation 95% on room air
The nurse performs a physical assessment for a client three days post-operative following a radical hysterectomy.Select three (3) assessment and vital sign findings that are highly concerning.
- A. Incisional pain
- B. Approximated wounds
- C. Pulse rate
- D. Foul smelling drainage
- E. Nausea after pain medication
- F. Oral temperature
- G. Purulent wound drainage
Correct Answer: D,F,G
Rationale: This client is demonstrating signs and symptoms of a surgical site infection. The findings requiring follow-up include the foul-smelling drainage that is purulent. Further, this client also has a concern for their oral temperature as it is a clinical fever.
Findings that are not highly concerning include the client’s incisional pain which is described as sore and is intermittent. This is an expected finding following surgery. The wounds being approximated is an optimal finding. The client’s pulse is within normal limits. Finally, nausea after pain medication is a common side-effect.
The nurse in the postanesthesia care unit (PACU) cares for a client who had an appendectomy. Which of the following client assessments warrants immediate follow-up?
- A. has breath sounds that are high-pitched and crowing
- B. reports incisional pain at a level of '5' on a scale of 0 (no pain) to 10 (severe pain)
- C. has a capillary blood glucose of 115 mg/dL [70-110 mg/dL]
- D. reports persistent nausea following the administration of an anti-emetic
Correct Answer: A
Rationale: High-pitched, crowing breath sounds suggest airway obstruction or stridor, a critical finding requiring immediate intervention to ensure airway patency. Moderate pain, slightly elevated glucose, and nausea are less urgent.
A school nurse is discussing poison prevention and management with a group of parents. Which statement by parents would indicate a need for additional teaching?
- A. Containers of poisonous liquids need to be properly labeled.
- B. In the event gasoline is ingested by my child, vomiting should be induced.
- C. I may be able to give my child milk or water to dilute a corrosive poison while I rush them to the hospital.
- D. All poisonous materials should be securely stored away from children.
Correct Answer: B
Rationale: Inducing vomiting for gasoline ingestion is dangerous due to aspiration risk. Labeling, diluting corrosives (if advised), and secure storage are correct.