Nokea
The nurse is caring for assigned clients. Which of the following clients should the nurse identify is at the highest risk for falling?
- A. 88-year-old admitted with a chest tube secondary to pneumothorax and has a history of dementia
- B. 44-year-old admitted with heart failure, has a peripheral IV, and receiving IV furosemide
- C. 33-year-old admitted with cholecystitis, has a peripheral IV, and is receiving IV hydromorphone
- D. 28-year-old admitted with bacteremia is receiving intravenous fluids via central line and is diaphoretic
Correct Answer: A
Rationale: The 88-year-old with dementia is at highest fall risk due to age and cognitive impairment.
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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.
The nurse is taking a sample of the fluid pulled from a nasogastric tube to ensure proper placement. The nurse recognizes that the gastric pH confirming proper placement in the stomach is
- A. 3.4
- B. 7
- C. 5.9
- D. 8
Correct Answer: A
Rationale: A gastric pH of ≤5.5 (e.g., 3.4) confirms NGT placement in the stomach. Higher pH values (7 or 8) suggest intestinal or respiratory placement.
The nurse is caring for a client who has generalized urticaria. Which disease transmission precautions should the nurse implement?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: D
Rationale: Generalized urticaria is typically non-infectious (e.g., allergic), requiring only standard precautions. Transmission-based precautions are unnecessary.
The nurse is educating a client who has stomatitis on oral care. Which of the following recommendations would be appropriate?
- A. Recommend the client swish and spit alcohol mouthwash.
- B. Provide lemon glycerin swabs in between meals.
- C. Recommend the client swish and spit saline mouthwash.
- D. Instruct the client to cleanse their mouth with chlorhexidine.
Correct Answer: C
Rationale: Saline mouthwash soothes stomatitis without irritation. Alcohol mouthwash and lemon swabs are harsh, and chlorhexidine may be prescribed but isn’t the primary recommendation.
The nurse cares for a client in the outpatient surgical center who is scheduled for a cholecystectomy
Item 1 of 1
Nurses' Note
0730 – The client arrives at the preoperative area with his family. He reports that he is anxious about the procedure. The pre-operative assessment was completed at this time. 20-gauge peripheral vascular access established in the right antecubital space. + blood return and flushes without resistance. The client reports no pain at the insertion site.
The nurse reviews the completed pre-operative assessment.Select the findings on the assessment that require follow-up
- A. ID verified and band applied
- B. The surgeon has not obtained informed consent
- C. Client took his prescribed phenytoin with a sip of water this morning
- D. The client reports his last meal and fluid intake was the previous day at 2200
- E. The client stated he was going to drive himself home after the procedure
Correct Answer: B,D
Rationale: Assessment items requiring follow-up include the informed consent not yet obtained by the surgeon. Before further preoperative activities may continue, the nurse must ensure this is completed to avoid unnecessary diagnostic testing and intervention. Additionally, the client will not be permitted to drive themselves home after this procedure because this involves general anesthesia. Activities requiring significant concentration, operation of heavy machinery, or driving are typically prohibited 24 hours following the initiation of general anesthesia.
The other assessment findings do not require intervention. ID banding and verification are expected during the preoperative process. The client's ID will also be verified in the intraoperative and postoperative processes. Medications such as phenytoin can be taken with a sip of water to prevent seizure activity. The client has been NPO for approximately eight hours, sufficient time to prevent aspiration.