Nokea
The nurse is conducting an in-service for nursing students. It would be appropriate for the nurse to state which of the following procedures requires a sterile technique? Select all that apply.
- A. Changing the dressing for a central line
- B. Inserting an indwelling urinary catheter
- C. Removing a peripheral vascular access device
- D. Suctioning an endotracheal tube with in-line suction
- E. Inserting a nasogastric tube (NGT)
Correct Answer: A,B,D
Rationale: Sterile technique is required for central line dressing changes, indwelling urinary catheter insertion, and endotracheal suctioning due to the risk of introducing pathogens into sterile areas.
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The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
- A. Discomfort while speaking
- B. Frequent swallowing
- C. Drowsiness
- D. Pain with occasional coughing
Correct Answer: B
Rationale: Frequent swallowing in a post-tonsillectomy child may indicate bleeding in the throat, as the child swallows blood, requiring immediate follow-up to prevent hemorrhage. Discomfort, drowsiness, and pain with coughing are expected findings and less urgent.
The nurse is caring for a client with a tracheostomy who requires suctioning. Which of the following actions by the nurse would indicate correct technique?
- A. Using a size 16 Fr catheter to suction the client.
- B. Withdrawing the suction catheter 1 to 2 cm before applying suction.
- C. Using 160 mm Hg of pressure when suctioning the client.
- D. Applying suction to the catheter for 25 seconds during withdrawal.
Correct Answer: B
Rationale: Withdrawing the catheter 1-2 cm before suctioning prevents mucosal trauma. A 16 Fr catheter may be too large, 160 mm Hg is excessive (80-120 mm Hg is typical), and suctioning for 25 seconds is too long (≤10-15 seconds).
The nurse is caring for a client two days post-operative following gastroduodenostomy. After reviewing the clinical data, the nurse should take which action?
- A. obtain a prescription for an antihypertensive
- B. determine if the client's pain is being controlled
- C. assess the client's surgical wound for signs of infection
- D. notify the physician for concerns of hypovolemic shock
Correct Answer: D
Rationale: Without specific clinical data, the priority for a client two days post-gastroduodenostomy is to assess for hypovolemic shock, a potential complication due to bleeding or fluid loss from the surgical site. This is more urgent than pain control, wound infection assessment, or antihypertensive needs, which require specific clinical indicators.
Which of the following responses should the nurse avoid when communicating with a client who has just received a poor prognosis? Select all that apply.
- A. My mother has the same thing.
- B. I'll sit with you for a while.
- C. I think you should try having surgery.
- D. Don't cry, everything is going to be okay.
- E. Do you have any questions for me right now?
Correct Answer: A,C,D
Rationale: Avoid personal anecdotes, medical advice, or minimizing emotions, as they dismiss the client’s feelings. Offering presence and open-ended questions are therapeutic.
The nurse observes that a fire has ignited in the client's room. After removing the client from the room, the nurse should then
- A. activate the fire alarm.
- B. extinguish the fire.
- C. contact the nursing supervisor.
- D. close the door to the client's room.
Correct Answer: A
Rationale: Following the RACE protocol (Rescue, Alarm, Contain, Extinguish), after rescuing the client, the nurse should activate the fire alarm to alert others and initiate emergency response.