Nokea
The nurse is conducting a staff education program on managing chemotherapy spills. Which actions should the nurse recommend be taken in the event of a chemotherapy spill? Select all that apply.
- A. Contain the spill using plastic-backed absorbent sheets or spill pads.
- B. Wear sterile gloves when cleaning the spill.
- C. Immediately remove any contaminated clothing and wash the affected skin with soap and water.
- D. Research the appropriate cleaning agent based on the spilled drug.
- E. Leave the spill area unattended until a supervisor arrives.
- F. Implement airborne precautions after the spill has been cleaned.
Correct Answer: A,C
Rationale: Containing the spill and decontaminating skin/clothes are critical. Sterile gloves are unnecessary, researching during a spill delays action, leaving unattended is unsafe, and airborne precautions are irrelevant.
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The nurse supervises a student assisting a client with left-sided weakness in performing activities of daily living. Which action by the student nurse requires the nurse to intervene? The student nurse
- A. Puts the client's affected (weaker) arm in the shirt's sleeve first.
- B. Places shoes with velcro straps on the client's feet.
- C. Places the wheelchair as close to the bed as possible on the client's affected (weaker) side.
- D. Places the hairbrush in the client's unaffected (stronger) hand.
Correct Answer: C
Rationale: Wheelchair on the affected side hinders transfer; it should be on the unaffected side. Dressing the weaker arm first, velcro shoes, and stronger hand use are correct.
The nurse is observing a newly hired nurse insert a nasogastric tube (NGT). Which action by the newly hired nurse requires follow-up?
- A. Advances the tube during the client's inspiration.
- B. Hands the client a cup of water and straw.
- C. Positions the client's head-of-bed at 90 degrees.
- D. Washes the client's bridge of nose with soap and water.
Correct Answer: A
Rationale: Advancing an NGT during inspiration increases the risk of tracheal placement. Providing water, elevating the bed to 90 degrees, and cleaning the nose are appropriate actions.
The nurse is preparing a client for a clinical breast exam by the physician. To facilitate an effective exam, the nurse should position the client
- A. Supine with arms at the side and a pillow under both knees
- B. Left lateral with the head resting on a pillow and the arm over the head
- C. Sitting forward with a pillow behind the shoulder blades with hands on the hips
- D. Supine, with the arm on the side raised behind the head, and a small pillow under the shoulder
Correct Answer: D
Rationale: Supine with the arm raised and a pillow under the shoulder flattens the breast tissue, facilitating palpation. Other positions are less effective for breast exams.
The nurse plans to care for a client admitted with Haemophilus influenzae, type b Meningitis. When caring for this client, the nurse should gather which appropriate personal protective equipment (PPE)?
- A. boot (shoe) covers
- B. face shield
- C. surgical mask
- D. gown
Correct Answer: C
Rationale: Haemophilus influenzae, type b meningitis requires droplet precautions, which include wearing a surgical mask when within 3 feet of the client. Boot covers, face shields, and gowns are not specifically required unless additional risks (e.g., splashing) are present.
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• Nurses' Notes
0920: Client presents for a follow-up visit. Client reports increased difficulty with activities of daily living because of dyspnea. Reports pain and swelling in both lower extremities that increases with movement. "Washing my hair now takes me an hour instead of fifteen minutes." Transverse surgical incision was pink, approximated, and crusted—9 inches in length. Two Jackson-Pratt drains contained a total of 15 mL of serumlike drainage. Incisional pain reported at a '4' on the Numerical Rating Scale. Endorses increased incisional pain while coughing. The client reports full adherence to postoperative enoxaparin self-injections. She reports ejecting the air bubble prior to injection. Reports relief with prescribed oxycodone-acetaminophen but experiences generalized itching and drowsiness after.
• Medical History
• gastric bypass surgery performed two years ago
• dyslipidemia
• diabetes mellitus (type two)
• Vital Signs
• T 99.0°F (37.2°C); HR 90 beats/min; RR 18 breaths/min; BP 119/67 mm Hg; Pulse oximetry 96% on room air.
The nurse in the medical office is caring for a 41-year-old client who is 2-week postoperative abdominoplasty. Which of the following assessment findings require immediate follow-up? Select all that apply.
- A. wound assessment findings
- B. tolerance with activities of daily living
- C. pain in lower extremities
- D. enoxaparin self-injections
- E. pulse, respirations, and blood pressure
Correct Answer: B,C,D
Rationale: Tolerance with activities of daily living. The client reports increased difficulty with activities of daily living (ADLs) due to dyspnea, which could indicate a significant complication, such as pulmonary embolism (PE). Dyspnea, especially in the postoperative period, should always be investigated promptly, as it could be a sign of a PE, which is a life-threatening emergency. Immediate follow-up is necessary to rule out PE or other respiratory or circulatory issues. Pain in lower extremities. Pain and swelling in the lower extremities that increase with movement could suggest deep vein thrombosis (DVT). This complication is especially concerning in a postoperative patient on anticoagulation therapy (enoxaparin). DVT can lead to pulmonary embolism if the clot dislodges, which could cause dyspnea. This requires immediate follow-up to assess for DVT and initiate treatment if necessary. The client reports full adherence to postoperative enoxaparin self-injections and mentions ejecting the air bubble before injection. This is an incorrect technique; ejecting the air bubble can result in an underdose of the medication, potentially leading to ineffective anticoagulation. This can increase the risk of complications like DVT or VTE. Correct technique is crucial to ensure proper dosing. Immediate follow-up is required to educate the client about appropriate injection techniques (not ejecting the air bubble) to prevent these risks.Wound assessment findings. The transverse surgical incision is described as pink, approximated, and crusted, which are normal findings in the early postoperative period. These findings suggest no signs of infection or delayed wound healing. Therefore, no immediate follow-up is required for this finding.Incision pain level and characteristics. The client reports incisional pain at a level of 4 on the Numerical Rating Scale and increased pain when coughing. This level of pain is within a manageable range for a postoperative patient. The description of the pain as incisional and aggravated by coughing is consistent with expected postoperative discomfort. The pain level is manageable, and this is not a priority concern for immediate follow-up unless it becomes severe or is associated with other complications (e.g., infection or dehiscence).