Nokea
The nurse is preparing to change the dressing of a client with a venous access device. Because it is the first time the nurse has performed the skill, he reads the unit policy manual and asks another nurse how to best perform the dressing change. The skill level of the nurse at this time is best described as:
- A. Novice
- B. Proficient
- C. Competent
- D. Expert
Correct Answer: A
Rationale: A nurse performing a skill for the first time, relying on guidelines and assistance, is a novice. Higher levels require experience and independence.
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A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. Obtaining a Guthrie Blood Test on a four-day-old infant.
- B. Massaging lotion on the abdomen of a three-year-old diagnosed with Wilm's tumor.
- C. Instructing a five-year-old asthmatic to blow on a pinwheel.
- D. Playing kickball with a 10-year-old with juvenile arthritis (JA).
Correct Answer: B
Rationale: Strategy: 'Would be considered negligence' indicates an incorrect action. (1) obtain after ingestion of protein, no later than 7 days after delivery (2) correct-manipulation of mass may cause dissemination of cancer cells (3) this exercise extends expiratory time and increases expiratory pressure (4) excellent moving and stretching exercise
The nurse is caring for a client who is receiving a continuous IV infusion of insulin for diabetic ketoacidosis. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 200 mg/dL.
- B. Potassium of 3.0 mEq/L.
- C. pH of 7.30.
- D. Sodium of 135 mEq/L.
Correct Answer: B
Rationale: Hypokalemia (potassium 3.0 mEq/L) is a serious complication in diabetic ketoacidosis treatment, as insulin drives potassium into cells, risking arrhythmias. Options A, C, and D are less urgent: glucose 200 mg/dL is improving, pH 7.30 is near normal, and sodium 135 mEq/L is normal.
A client asks the home care nurse to look at the bruises on her arms and legs. The woman also tells the nurse that her gums bleed when she uses dental floss or brushes her teeth. The client is taking all of the following medications. Which is most likely related to the client's symptoms?
- A. Metformin (Glucophage)
- B. Estrogen (Premarin)
- C. Atenolol (Tenormin)
- D. Ibuprofen (Motrin)
Correct Answer: D
Rationale: Ibuprofen, an NSAID, can inhibit platelet function, causing bruising and bleeding gums. Other medications are less likely to cause these symptoms.
A clear liquid diet is ordered for an adult following surgery. All of the following are on the client's tray. Which should be removed by the nurse?
- A. Ice cream
- B. Beef broth
- C. Apple juice
- D. Iced tea
Correct Answer: A
Rationale: Ice cream is not a clear liquid, as it contains dairy solids, and must be removed from a clear liquid diet tray.
The nurse is observing a certified nursing assistant (CNA) caring for a client who has AIDS. Which action, if observed, is not correct?
- A. The CNA wears gloves when cleaning the client after an episode of fecal incontinence.
- B. The CNA uses chlorine bleach to wipe up blood after the client cut himself shaving.
- C. The CNA is observed giving the client a back rub without gloves on.
- D. The CNA wears a mask whenever entering the client's room.
Correct Answer: C
Rationale: Standard precautions require gloves during contact with non-intact skin or bodily fluids, including during a back rub for an AIDS client, to prevent transmission. Gloves for incontinence, bleach for blood, and masks (if indicated) are appropriate.