Nokea
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.
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The nurse is preparing to insert a nasogastric tube (NGT) for a client with abdominal distention. The nurse should place the client in which position for this procedure?
- A. Supine with the head of the bed elevated at 30 degrees
- B. Supine with the head of the bed 90 degrees
- C. Left-lateral position with the knees bent
- D. Right-lateral position with the knees bent
Correct Answer: B
Rationale: A 90-degree head-of-bed elevation facilitates NGT insertion by aligning the esophagus and reducing aspiration risk. Other positions are less effective.
The nurse reviews a client’s laboratory data before a scheduled surgery. Which laboratory data requires immediate follow-up?
- A. Sodium level
- B. Potassium level
- C. Blood Urea Nitrogen (BUN)
- D. Creatinine
Correct Answer: B
Rationale: Abnormal potassium levels can cause cardiac arrhythmias, a critical risk during surgery, requiring immediate follow-up. Sodium, BUN, and creatinine abnormalities are less immediately life-threatening but still important.
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 part of an infection control committee that is responding to an outbreak of norovirus in the long-term care facility. Which recommendation should the nurse make to prevent further transmission of this outbreak?
- A. Place face shields outside client rooms.
- B. Discontinue indwelling urinary catheters that are not medically necessary.
- C. Wipe down surfaces with hot, soapy water.
- D. Increase the frequency of cleaning and disinfection of client care areas.
Correct Answer: D
Rationale: Increased cleaning and disinfection of surfaces prevent norovirus spread via contaminated surfaces. Face shields, catheter discontinuation, and soapy water are less effective.
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.