Nokea
The nurse is caring for a client with a Sengstaken-Blakemore tube. The nurse performs safety checks at the beginning of the shift and ensures which priority item is readily available at the bedside?
- A. Trach kit
- B. Scissors
- C. Obturator
- D. Yankauer suctioning
Correct Answer: B
Rationale: A Sengstaken-Blakemore tube is used for esophageal variceal bleeding and has balloons that can cause airway obstruction if inflated improperly. Scissors must be at the bedside to cut the tube in an emergency. Trach kits, obturators, and Yankauer suction are not relevant.
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The nurse is preparing to admit a client following lumbar spinal fusion surgery. The nurse should instruct the unlicensed assistive personnel (UAP) to have which equipment at the bedside?
- A. Overhead trapeze
- B. Abduction pillow
- C. Transfer board
- D. Continuous passive motion (CPM)
Correct Answer: A
Rationale: An overhead trapeze assists with safe repositioning and mobility post-lumbar spinal fusion, reducing strain on the surgical site. Abduction pillows are used for hip surgeries, transfer boards aid general transfers, and CPM is for joint surgeries, not spinal fusion.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 4 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client with progressive multiple sclerosis.
- A. Obtain a referral for occupational therapy for fatigue and energy conservation training
- B. Promote rest by encouraging daytime napping over consistent nighttime sleep
- C. Encourage the client to walk to the mailbox at midday for sun exposure
- D. Instruct the client to increase fluid intake with caffeinated beverages
- E. Obtain an order for physical therapy for home mobility and coordination evaluation
- F. Educate the client on the early signs of cystitis and the importance of completing antibiotics
- G. Educate the client to wear slippers while walking inside
Correct Answer: A,E,F,G
Rationale: Occupational therapy, physical therapy, cystitis education, and slipper use are indicated to address fatigue, mobility, infection prevention, and fall risk. Daytime napping and midday sun exposure are not indicated due to heat sensitivity and inconsistent sleep.
The nurse is working with a group of students and a student asks what cyanosis means. What is the nurse's best response?
- A. Cyanosis is a condition characterized by a yellowish discoloration of the skin and mucous membranes due to excessive oxygenation.
- B. Cyanosis is the blue coloring of the skin and mucous membranes in the presence of poorly oxygenated blood.
- C. Cyanosis is the primary indication that the client has pneumonia.
- D. Cyanosis is the bluish discoloration of the skin and mucous membranes due to poor peripheral circulation, even in the presence of normal oxygen levels.
Correct Answer: B
Rationale: Cyanosis is blue discoloration due to poorly oxygenated blood. Yellowish discoloration is jaundice, it’s not specific to pneumonia, and circulation issues alone don’t cause it if oxygen is normal.
The nurse is teaching parents about fire safety in the home. Which of the following recommendations should the nurse make? Select all that apply.
- A. Use smoke detectors instead of carbon monoxide detectors
- B. Teach your child what the smoke detector sounds like and what to do when one is heard
- C. Teach children how to light a candle in the event of power failure
- D. Practice escaping from your home at least twice a year
- E. Ensure that electrical wiring is under rugs, not above them
- F. If a house fire occurs, call emergency services before evacuating
Correct Answer: B,D
Rationale: Teaching children about smoke detector sounds and escape actions, and practicing escape plans twice yearly, enhance fire safety. Both types of detectors are needed, candles pose risks, wiring under rugs is hazardous, and evacuation precedes calling services.
The nurse is teaching at an interdisciplinary conference focused on age-related changes. Which of the following are expected in the older adult? Select all that apply.
- A. Fatty tissue is redistributed
- B. Skin becomes less elastic
- C. Cardiac output increases
- D. Muscle mass increases
- E. Hormone production increases
- F. Visual and hearing acuity diminishes
Correct Answer: A,B,F
Rationale: Aging involves fat redistribution, less elastic skin, and diminished sensory acuity. Cardiac output, muscle mass, and hormone production decrease.