Nokea
The nurse is giving report to the NA on the care of four clients. The nurse should inform the NA to avoid taking a rectal temperature for which client?
- A. Adult who underwent ileostomy surgery because of a perforated bowel
- B. Adult who has a productive cough and is receiving oxygen by nasal cannula
- C. Adult who develops thrombocytopenia after receiving chemotherapy treatments
- D. Adult who has hypothermia after being outside in a below-zero temperature
Correct Answer: C
Rationale: C: Thrombocytopenia increases bleeding risk, making rectal temperatures unsafe. A: Ileostomy doesn't affect rectal area. B: Cough and oxygen don't contraindicate rectal temperatures. D: Rectal temperatures are used for hypothermia.
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The client with intermittent abdominal pain recently had a barium enema. The client calls the nurse to report passage of a soft-formed, pale-colored stool. What is the nurse's best response?
- A. This is an expected finding after administration of barium.
- B. Describe any abdominal pain you had when passing the stool.
- C. What foods or fluids did you eat after you completed the test?
- D. You need to increase the amount of water you are drinking.
Correct Answer: A
Rationale: A: Pale stools are expected due to residual barium. B: Pain doesn't cause pale stools. C: Diet doesn't affect barium-related stool color. D: Water aids barium passage but isn't indicated for soft stools.
The nurse needs nasotracheal suctioning. The nurse explains the procedure to the client and performs hand hygiene. Prioritize the nurse's remaining actions to perform the nasotracheal suctioning by placing each step in the correct order.
- A. Prepare suction supplies and equipment and pour sterile saline into a sterile container.
- B. Place finger over suction control port of catheter and suction intermittently while withdrawing the catheter.
- C. Put on sterile gloves.
- D. Lubricate the catheter with sterile saline, insert into naris, and advance into pharynx.
- E. When the client inhales, advance the catheter into the trachea.
- F. Pick up suction catheter with the dominant hand and attach it to connection tubing; avoid contamination of the glove on the dominant hand.
- G. Place tip into sterile saline container while applying suction to clear secretions from the tubing
Correct Answer: A,C,F,D,E,B,G
Rationale: A: Preparing supplies comes first. C: Sterile gloves maintain asepsis. F: Handling catheter keeps dominant hand sterile. D: Lubrication aids insertion. E: Advancing during inhalation ensures tracheal placement. B: Intermittent suction prevents trauma. G: Clearing tubing prevents reinsertion of secretions.
The intent of the Patient Self Determination Act (PSDA) of 1990 is to:
- A. enhance personal control over legal care decisions
- B. encourage medical treatment decision making prior to need
- C. give one federal standard for living wills and durable powers of attorney
- D. emphasize client education
Correct Answer: B
Rationale: The PSDA encourages advance directives to promote proactive medical decision-making, ensuring clients' wishes are honored before a crisis.
A spinal change occurring with pregnancy that alters mobility is:
- A. scoliosis.
- B. kyphosis.
- C. lordosis.
- D. ankylosing spondylitis.
Correct Answer: C
Rationale: The spinal change occurring with pregnancy is lordosis. This occurs due to the weight of the enlarging uterus and the affect of gravity.
The experienced nurse observes the student nurse caring for the client with the wet plaster cast illustrated. Which conclusion by the experienced nurse is correct?
- A. The student should not be touching the plaster cast because it is wet.
- B. The student should be using a pillow to lift the client's casted extremity.
- C. The student is correctly handling a wet plaster cast with the palms.
- D. The student should be using fingers and not the palms to handle the cast.
Correct Answer: C
Rationale: C: Using palms prevents indentations in wet casts. A: Wet casts can be touched to reposition. B: Pillows limit inspection of the cast underside. D: Fingers cause pressure points.