Nokea
The nurse is observing a staff member perform ear irrigation for an adult client with impacted cerumen. The nurse should intervene if the staff member is observed
- A. using a slow, steady flow of solution to irrigate the ear canal
- B. placing the client in a lying position with the head tilted toward the affected ear
- C. straightening the ear canal by pulling the pinna down and back
- D. directing the tip of the syringe and irrigation solution toward the top of the ear canal
Correct Answer: C
Rationale: Pulling the pinna down and back is incorrect for adults; it should be up and back. Slow flow , head tilt , and directing solution upward are correct.
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The precepting nurse supervising a graduate practical nurse would need to intervene when the graduate nurse violates the Health Insurance Portability and Accountability Act with which action? Select all that apply.
- A. Accesses the medical record of a client not currently assigned, but previously cared for, to assess client improvement.
- B. Advises the client transport technician, 'This client has fragile bones due to cancer, so move the client very carefully.'
- C. Asks a client, 'When were you diagnosed with diabetes?' in a semi-private room with the privacy curtain in place between beds.
- D. Interprets the results of a client's diagnostic testing to the unit clerk
- E. Writes a client's last name and room number on a whiteboard hanging in the nurse's station on which scheduled procedures are logged
Correct Answer: A,D,E
Rationale: Accessing unassigned records , sharing results with a clerk , and writing names on a public whiteboard violate HIPAA. Sharing relevant care info and private questioning are permissible.
The nurse is reinforcing postpartum discharge instructions to a client. Which instruction should the nurse include to promote newborn safety?
- A. Avoid using blankets to position the newborn in the car seat
- B. Place the newborn in the prone position in bed while sleeping
- C. Position the newborn's car seat in the back seat facing forward
- D. Remove pillows and loose blankets from the newborn's crib
Correct Answer: D
Rationale: Removing pillows and blankets from the crib reduces SIDS risk. Blankets in car seats are unsafe, prone sleeping increases SIDS risk, and forward-facing car seats are incorrect for newborns.
The nurse is caring for an acutely ill 10 year-old client. Which of the following assessment findings would require the nurses immediate attention?
- A. Rapid bounding pulse
- B. Temperature of 101.3 degrees Fahrenheit (38.5 degrees Celsius)
- C. Profuse diaphoresis
- D. Slow, irregular respirations
Correct Answer: D
Rationale: Slow, irregular respirations. A slow and irregular respiratory rate is a sign of fatigue in an acutely ill child. Fatigue can rapidly lead to respiratory arrest.
The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test?
- A. Client should be NPO after midnight
- B. Client should receive a sedative medication prior to the test
- C. Discontinue anti-coagulant therapy prior to the test
- D. No special preparation is necessary
Correct Answer: D
Rationale: This is a non-invasive procedure and does not require preparation other than client education.
The clinic nurse is reinforcing teaching to a client about levothyroxine, which the health care provider has prescribed for newly diagnosed hypothyroidism. Which statement made by the client indicates that further teaching is needed?
- A. I will need to get my blood drawn to see if I'm taking the right dose.
- B. I will probably need to take this the rest of my life.
- C. I will take this once a day in the morning.
- D. If this makes my stomach upset, I will take it with an antacid.
Correct Answer: D
Rationale: Antacids reduce levothyroxine absorption, requiring further teaching. Blood monitoring , lifelong use , and morning dosing are correct.