Nokea
The nurse is preparing to insert a nasogastric tube (NGT). Which action should the nurse take?
- A. Rinse the tube with warm, soapy water
- B. Perform hand hygiene
- C. Don sterile gloves
- D. Obtain a computed tomography (CT) scan to verify placement
Correct Answer: B
Rationale: Hand hygiene is essential before NGT insertion to prevent infection. Rinsing with soapy water is incorrect, clean gloves suffice, and CT is not used for verification.
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The nurse is preparing to remove a peripheral vascular access device. Which personal protective equipment (PPE) is necessary for this procedure?
- A. Fluid resistant gown
- B. Clean gloves
- C. Surgical mask
- D. Sterile gloves
Correct Answer: B
Rationale: Removing a peripheral vascular access device involves potential blood exposure, requiring clean gloves as standard precautions. A gown, surgical mask, or sterile gloves are not necessary unless additional risks (e.g., infection) are present.
The first bodily area to be washed during a complete bed bath is the:
- A. Inner canthus of the eye
- B. Cheeks
- C. Forehead
- D. Chin
Correct Answer: A
Rationale: Washing from the inner canthus of the eye outward prevents debris spread and is the starting point for a bed bath. Other areas follow.
The nurse is developing a care plan for a child scheduled to be admitted to the oncology unit to receive treatment for leukemia. To facilitate effective transition to the hospitalized environment, the nurse should recommend that the parents
- A. Purchase new toys for the child.
- B. Allow flexibility in the daily routine, so it changes often.
- C. Bring in the child's favorite toys from home.
- D. Limit parental visitation to specific times.
Correct Answer: C
Rationale: Familiar toys provide comfort, easing the hospital transition. New toys lack familiarity, flexible routines disrupt stability, and limited visitation increases anxiety.
The nurse is presenting a home safety class on carbon monoxide toxicity to a group of older adults. Which statement would be appropriate for the nurse to make to the group of clients?
- A. Carbon monoxide is a gas that is gray in color and deadly.
- B. Carbon monoxide is a clear and odorless gas.
- C. Early signs of carbon monoxide toxicity include nose bleed and tremors.
- D. Carbon monoxide is a gas that smells like rotten eggs.
Correct Answer: B
Rationale: Carbon monoxide is a colorless, odorless gas, making detectors essential. It is not gray, does not smell like rotten eggs, and early signs include headache, not nosebleeds or tremors.
The nurse is caring for a client in bilateral soft wrist restraints. The nurse should assess the client's? Select all that apply.
- A. behavioral status.
- B. skin integrity.
- C. bowel sounds.
- D. neurovascular status.
- E. need for restraint.
Correct Answer: A,B,D,E
Rationale: Behavioral status, skin integrity, neurovascular status, and need for restraint must be assessed to ensure safety and appropriateness of restraints. Bowel sounds are unrelated.