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The nurse is observing a student collect vital signs on a client. Which action by the student requires the nurse to intervene? Select all that apply.
- A. Obtains the blood pressure with a cuff bladder width of at least 40% of arm circumference.
- B. Places the BP cuff over the client's clothing garment.
- C. Requests the client remove their hearing aid before obtaining a tympanic temperature.
- D. Assesses the client's respirations after obtaining the pulse rate.
- E. Obtains blood pressure by placing the client's upper extremity at the level of their heart.
- F. Places the pulse oximeter probe on the client's finger that has edema.
Correct Answer: B,F
Rationale: Placing the BP cuff over clothing and using an edematous finger for pulse oximetry can yield inaccurate readings. Other actions are correct.
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The nurse recognizes which of the following is considered an external disaster?
- A. Computer system failure
- B. A walkout and strike by nursing staff
- C. Mass shooting at a nearby park
- D. Chemical leak in the critical care units
Correct Answer: C
Rationale: A mass shooting at a nearby park is an external disaster, as it occurs outside the facility and impacts hospital operations. The others are internal disasters.
The nurse in the emergency department (ED) is caring for a child with erythema infectiosum (Fifth disease). Which transmission-based precautions should the nurse implement?
- A. Standard
- B. Droplet
- C. Contact
- D. Airborne
Correct Answer: A
Rationale: Erythema infectiosum is typically non-infectious once the rash appears, requiring only standard precautions.
The nurse needs to assess the use of complementary and alternative medicine (CAM) because:
- A. Patients should be warned that most CAM therapies are potentially dangerous
- B. Additional treatment may not be needed if the patient is using CAM
- C. CAM therapy could interact with prescription and over-the-counter medications
- D. Most CAM therapies are essentially ineffective
Correct Answer: C
Rationale: CAM therapies can interact with medications, affecting efficacy or safety. Not all CAM is dangerous, ineffective, or a replacement for conventional treatment.
The nurse conducts safety rounds within the nursing unit. Which observation requires followup? Select all that apply.
- A. The client's armband was affixed to the bedside table.
- B. The client's telephone number and name were used as identifiers.
- C. Multiple blood specimen tubes are labeled before specimen collection.
- D. A room number is used as an identifier during medication administration.
- E. Verifies client's name, date of birth, consent, site, and procedure during a time out process.
Correct Answer: A,B,C,D
Rationale: Armbands on tables, using telephone numbers, pre-labeling tubes, and room numbers as identifiers risk errors. Verifying name, date of birth, and procedure details is correct.
The nurse is caring for a client who is two days postoperative following a right femoral popliteal bypass surgery. The client reports worsening pain, and the assessment showed swelling and ecchymosis at the incision sites. The nurse should initially
- A. Apply pressure to sites with sandbag
- B. Palpate pedal pulses
- C. Assess for signs of claudication
- D. Apply warm compress to incision sites
Correct Answer: B
Rationale: Worsening pain, swelling, and ecchymosis at the incision sites suggest possible complications such as hematoma or compromised vascular flow. Palpating pedal pulses is the priority to assess the patency of the bypass graft and ensure adequate distal perfusion. Applying pressure or warm compresses could exacerbate bleeding or swelling, and claudication assessment is less urgent than confirming vascular integrity.