Nokea
The nurse is caring for a client with a tracheostomy. Which of the following items is essential to have at the bedside?
- A. Air humidifier
- B. Inner cannula
- C. Nasal cannula oxygen
- D. Tracheostomy brush
Correct Answer: B
Rationale: An inner cannula is essential for tracheostomy care to replace or clean it if obstructed. Humidifiers, nasal cannulas, and brushes are not critical bedside items.
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The nurse is preparing for the first interaction with a client recently admitted to the hospital. Which of the following would help establish trust during this encounter? Select all that apply.
- A. Make sure the client's bed is set up properly ahead of time.
- B. Review the client's name, diagnosis, and anticipated length of stay before they arrive.
- C. Speak confidently and do not tell the client that one of the nurses providing care is a student nurse.
- D. Show the client how to use the bed and call light.
- E. Avoid spending too much time talking with the client.
- F. Ask about the client's expectations and concerns when taking the health history.
Correct Answer: A,B,D,F
Rationale: Preparing the environment, knowing client details, demonstrating equipment, and addressing concerns build trust. Avoiding student disclosure is deceptive, and limiting talk time hinders rapport.
While scheduling a client for thoracentesis, the nurse understands which of the following is the most preferred position for the procedimiento?
- A. Sitting up, leaning over a bedside table, and feet supported on the ground or stool.
- B. The head of the bed flat with the patient lying on the unaffected side.
- C. Prone position with both arms extended above the head.
- D. The head of the bed elevated 45 degrees, and the patient lying on the affected side.
Correct Answer: A
Rationale: Sitting up and leaning forward maximizes lung expansion and pleural fluid access for thoracentesis. Other positions restrict access or increase complication risk.
The nurse supervises unlicensed assistive personnel (UAP) assist a bed-bound client with oral hygiene. Which action by the UAP requires follow-up? Select all that apply.
- A. Raises the head of the bed (HOB) to 15 degrees
- B. Positions the toothbrush bristles at a 45-degree angle to the gum line
- C. Performs hand hygiene and applies clean gloves
- D. Removes the towel and places it in a biohazard bag
- E. Applies moisturizing lubricant to the lips after brushing and rinsing
Correct Answer: A,D
Rationale: A 15-degree HOB increases aspiration risk; it should be 30-45 degrees. Towels go in regular laundry, not biohazard. Other actions are correct.
The nurse participates in a task force to reduce errors related to telephone and verbal orders. The nurse should recommend that
- A. unlicensed assistive personnel (UAP) can take a physician's telephone prescription.
- B. use more abbreviations when transcribing a physician's order.
- C. when repeating an order back to the physician, repeat the numbers individually.
- D. verbal and telephone orders are limited to emergency situations.
- E. transcribing telephone and verbal orders be delayed until a second nurse can review the order.
Correct Answer: C,D
Rationale: Repeating numbers individually and limiting verbal orders to emergencies reduce errors. UAP cannot take prescriptions, abbreviations increase errors, and delays risk patient safety.
The nurse assesses a client's central venous catheter dressing, and it appears loose and wet. The nurse should take which action?
- A. Reinforce the dressing with paper tape
- B. Remove the dressing and the central vascular device
- C. Apply a clean occlusive dressing to the site
- D. Clean the site and apply a new sterile dressing
Correct Answer: D
Rationale: Cleaning the site and applying a new sterile dressing prevents infection and ensures catheter security.