Nokea
The nurse is preparing to prime a new line of IV tubing. The nurse understands that priming intravenous tubing is crucial because it prevents which treatment complication?
- A. Medication toxicity
- B. Infiltration
- C. Air embolism
- D. Extravasation
Correct Answer: C
Rationale: Priming IV tubing removes air, preventing air embolism, a potentially fatal complication. Other complications are unrelated to priming.
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The nurse observes a student inserting an indwelling urinary catheter into a female client. Which action by the student requires follow-up by the nurse? The student
- A. Applies clean gloves to cleanse the perineal area with soap and water.
- B. Asks the client to bear down as the catheter is slowly inserted through the urethral meatus.
- C. Separates the labia with the fingers of the dominant hand when cleaning with antiseptic solution.
- D. Secures the catheter tubing to the inner thigh.
- E. Attaches the drainage bag to the side rails of bed.
Correct Answer: A,C,E
Rationale: Sterile gloves are required for perineal cleaning, the non-dominant hand holds the labia, and the drainage bag should be attached below the bladder level, not to side rails. Bearing down and securing to the inner thigh are correct.
The nurse is caring for a postoperative client who is ordered to use an incentive spirometer. The nurse understands that this device will help prevent which complication?
- A. venous thromboembolism
- B. obstructive sleep apnea
- C. hypostatic pneumonia
- D. aspiration pneumonia
Correct Answer: C
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis, reducing the risk of hypostatic pneumonia in postoperative clients with limited mobility. It does not directly prevent venous thromboembolism, obstructive sleep apnea, or aspiration pneumonia.
The nurse is caring for a client immediately following hypophysectomy. The nurse should position the client
- A. Trendelenburg
- B. Side-lying
- C. high-Fowler's
- D. Reverse Trendelenburg
Correct Answer: C
Rationale: High-Fowler’s position (head elevated 30–45 degrees) is recommended post-hypophysectomy to reduce intracranial pressure and prevent cerebrospinal fluid leakage. Trendelenburg and reverse Trendelenburg could increase pressure or disrupt surgical site healing, and side-lying is less effective for this purpose.
Ergonomic principles are most closely associated with:
- A. Normal bodily alignment
- B. The control of infection
- C. Preventing congenital abnormalities
- D. Preventing hospital-acquired infections
Correct Answer: A
Rationale: Ergonomics focuses on optimizing bodily alignment to reduce strain. Infection control and congenital abnormalities are unrelated.
The nurse is assessing a client with a history of chronic pain. Which chronic pain assessment focuses on wellness?
- A. Birth history, immunizations, as well as growth and development
- B. Medical history, chronic pain symptoms, and psychosocial factors.
- C. Religion
- D. Sensory deficits, pain management, medication history
Correct Answer: B
Rationale: A wellness-focused chronic pain assessment includes medical history, pain symptoms, and psychosocial factors to optimize quality of life. Birth history, religion, or sensory deficits alone are insufficient.