Nokea
The nurse is performing health screenings on a group of refugees. The nurse plans on performing which screening for this population group? Select all that apply.
- A. Hypothyroidism
- B. Attention deficit hyperactivity disorder (ADHD)
- C. Pulmonary tuberculosis
- D. Intestinal parasites
- E. Viral hepatitis
Correct Answer: C,D,E
Rationale: Refugees are at higher risk for tuberculosis, intestinal parasites, and viral hepatitis due to living conditions and exposure risks.
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The nurse cares for a client with a double-lumen peripherally inserted central catheter (PICC). Which of the following actions would be appropriate for the nurse to take?
- A. Assign the client to a private room.
- B. Change the dressing daily using sterile technique.
- C. Flush heparin prior to discontinuation.
- D. Aspirate each lumen for blood return and then flush.
Correct Answer: D
Rationale: Aspirating for blood return and flushing ensures PICC patency. Private rooms, daily dressing changes, and heparin flushing are not standard unless specified.
The nurse is planning a staff development conference about ways to prevent the transmission of the hepatitis C virus to healthcare workers. It would be appropriate for the nurse to cover which topic?
- A. How to obtain the HCV vaccine
- B. How to dispose of sharps safely
- C. How to dispose of urine and feces for those with HCV
- D. Isolation precautions for individuals with HCV
Correct Answer: B
Rationale: Safe sharps disposal prevents needlestick injuries, a primary transmission route for HCV. No vaccine exists, and urine/feces disposal or isolation are less relevant.
The nurse is taking a sample of the fluid pulled from a nasogastric tube to ensure proper placement. The nurse recognizes that the gastric pH confirming proper placement in the stomach is
- A. 3.4
- B. 7
- C. 5.9
- D. 8
Correct Answer: A
Rationale: A gastric pH of ≤5.5 (e.g., 3.4) confirms NGT placement in the stomach. Higher pH values (7 or 8) suggest intestinal or respiratory placement.
The nurse is assessing a client who had gastric bypass surgery two days ago. The nurse should prioritize assessing the client for
- A. venous thromboembolism
- B. their current weight
- C. nausea and vomiting
- D. surgical site infection
Correct Answer: C
Rationale: Nausea and vomiting are priority assessments post-gastric bypass due to the risk of anastomotic leaks or obstruction, which can be life-threatening. Venous thromboembolism and surgical site infection are concerns but less immediate, and weight assessment is not a priority at this stage.
The charge nurse is performing safety rounds on clients in the nursing unit. Which observation by the charge nurse requires follow-up? A client with
- A. An indwelling urinary catheter bag secured to the bed frame.
- B. Delirium tremens having a peripheral vascular access device (VAD) inserted.
- C. Right-sided weakness with their cane on the left side of the bed.
- D. A belt restraint was applied and secured over the chest.
Correct Answer: C,D
Rationale: A cane on the left side for right-sided weakness is inaccessible, and a belt restraint over the chest is unsafe, risking respiratory compromise. Catheter bag placement and VAD in delirium tremens are appropriate.