Nokea
The nurse is preparing to obtain capillary blood glucose (CBG) for a client with diabetes mellitus. The nurse should take which action? Select all that apply.
- A. Apply gloves for this procedure
- B. Have the client wash their hands with soap and water prior to blood collection
- C. Collect the second blood drop on the test strip
- D. Prick the central part of the finger for the sample
- E. Clean and disinfect the glucometer in between uses
Correct Answer: A,B,C,E
Rationale: Gloves protect against blood exposure, hand washing ensures a clean sample, the second drop avoids contamination, and disinfecting the glucometer prevents infection. Pricking the central finger part is less preferred than the side.
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A nurse is caring for a client who has complete immobility and is bedbound. Which of the following complications should the nurse monitor for? Select all that apply.
- A. Peripheral neuropathy
- B. Increased peristalsis leading to diarrhea
- C. Joint contractures
- D. Increased bone density
- E. Peripheral edema
- F. Pneumonia
Correct Answer: C,E,F
Rationale: Immobility causes contractures, edema, and pneumonia due to reduced mobility and lung expansion. Neuropathy and increased peristalsis are unrelated, and bone density decreases.
The nurse is performing perineal care for a female client. It would be appropriate for the nurse to
- A. Clean the client from the anal area to the urethral area.
- B. Vigorously dry the area with a clean towel.
- C. Ensure that the client's door is kept closed during the procedure.
- D. Use warm water and a soap containing alcohol.
Correct Answer: C
Rationale: Closing the door ensures privacy during perineal care. Cleaning backward risks infection, vigorous drying irritates, and alcohol-soap is harsh.
The nurse is caring for a client who has been physically violent towards staff. The nurse prepares to restrain the client using
- A. soft wrist restraints.
- B. mitten restraints.
- C. elbow restraints.
- D. waist belt restraint.
Correct Answer: A
Rationale: Soft wrist restraints are appropriate for preventing harm in violent clients while allowing some movement. Other options are less suitable.
The nurse is performing a home safety assessment for an older adult. Which intervention would be appropriate for the nurse to recommend to reduce the client's risk of falling?
- A. Installation of non-slip mats in the kitchen
- B. Placement of furniture in the center of rooms
- C. Remove locks from doors
- D. Painting walls with bright colors
Correct Answer: A
Rationale: Non-slip mats reduce fall risk by improving traction. Furniture placement, door locks, and wall color do not directly address falls.
A nurse is caring for a client with a suspected bowel obstruction who requires a nasogastric (NG) tube insertion. Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Begin inserting the tube. Have the client relax and flex their head toward their chest after the tube has passed through the nasopharynx.
- B. Verify tube placement with a radiograph. Check agency policy for specific guidelines.
- C. Encourage the client to swallow by taking small sips of water when possible. Then advance the tube as the client swallows.
- D. Determine the length of the tube to be inserted. Measure the distance from the tip of the nose to the earlobe to the xiphoid process (NEX) of the sternum.
- E. Temporarily anchor the tube to the nose with a small piece of tape.
- F. Educate the client on what is going to take place. Instruct client to relax and breathe normally while occluding one naris. Then repeat this action for the other nare. Select the nostril with greater airflow.
- G. Advance the tube each time the client swallows until you reach the desired length.
Correct Answer: F,D,A,C,G,E,B
Rationale: The correct order is: educate the client (F), measure tube length (D), begin insertion (A), encourage swallowing (C), advance to desired length (G), anchor the tube (E), verify placement with radiograph (B). This sequence ensures safe and effective NGT insertion.