Nokea
The nurse is preparing to administer an enema to a client who is experiencing constipation. Place the following actions in the order listed:
- A. Lubricate the tip of the enema applicator
- B. Remove the applicator after the solution has been infused.
- C. Explain the procedure and help the client lie on the left side with their knees flexed and back toward you
- D. Release clamp
- E. Insert into the client's rectum
- F. Fill the enema bag, prime, and clamp tubing
Correct Answer: F,A,C,E,D,B
Rationale: The correct order is: fill and prime bag (F), explain and position client (C), lubricate tip (A), insert tube (E), release clamp (D), remove applicator (B). This ensures safe administration.
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Following a detailed conversation between a nurse and a client regarding autologous blood donations, which of the following statements, if made by the client, would indicate the need for additional education on the topic?
- A. Autologous donations require a health care provider's (HCP) order
- B. There is no age limitation for autologous blood donations
- C. I can begin autologous blood donations five weeks before my surgery date and continue up until 72 hours before surgery
- D. My autologous blood donation will be screened for infectious diseases
Correct Answer: B
Rationale: There are age limitations for autologous blood donations, typically excluding very young or elderly patients due to health risks. The other statements are correct: a provider’s order is required, donations can start five weeks and stop 72 hours before surgery, and blood is screened for infectious diseases.
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.
The nurse is caring for a client scheduled for electroconvulsive therapy (ECT). To prevent complications during and after the procedure, the nurse should assess the client's
- A. sensation in the lower extremities
- B. dentition
- C. grip strength
- D. peripheral vision
Correct Answer: B
Rationale: Assessing dentition is critical before ECT to identify loose teeth or dental appliances that could pose an airway risk during induced seizures. Sensation, grip strength, and peripheral vision are not directly related to ECT complications.
The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure?
- A. Nasogastric tube (NGT)
- B. Bottle of sterile water
- C. Suction equipment
- D. Tracheostomy
Correct Answer: C
Rationale: Cheiloplasty is a surgical repair of a cleft lip, which can affect the infant’s ability to feed and maintain a clear airway. Suction equipment is essential at the bedside to clear secretions or blood from the oral cavity, preventing airway obstruction and ensuring airway patency. A nasogastric tube is not typically required unless feeding difficulties are severe. Sterile water is not a priority for immediate postoperative care, and a tracheostomy is not indicated for this procedure.
The nurse is ambulating a client who is wearing a gait belt. The client begins to fall. The nurse should take which appropriate action to minimize injury?
- A. Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor.
- B. Let go of the gait belt, grab the client under each arm, and gently lower the client to the floor.
- C. Grasp the gait belt, and instruct the client to fall gently down to the floor in a side-lying position.
- D. Hold the gait belt, and lower the client to the floor by using a narrow base of support.
Correct Answer: A
Rationale: Using the gait belt to guide the client against the nurse’s leg minimizes injury. Letting go, instructing a side-lying fall, or using a narrow base increases risk.