Nokea
The nurse is preparing to suction the client with a tracheotomy. The nurse notes a previously used bottle of normal saline on the client's bedside table. There is no label to indicate the date or time of initial use. The nurse should:
- A. Lip the bottle and use a pack of sterile 4x4 for the dressing
- B. Obtain a new bottle and label it with the date and time of first use
- C. Ask the ward secretary when the solution was requested
- D. Label the existing bottle with the current date and time
Correct Answer: B
Rationale: Using an unlabeled, previously opened saline bottle risks contamination; a new, labeled bottle ensures sterility.
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The nurse is assisting a client who has experienced a left-sided cerebral vascular accident. The client requires assistance with personal hygiene. Which intervention should the nurse do initially?
- A. provide positive feedback
- B. place hygiene items on the client's left side
- C. provide assistive devices
- D. assess abilities and level of deficit
Correct Answer: D
Rationale: Assessing the client’s abilities and deficits first guides appropriate hygiene assistance, considering left-sided neglect or weakness.
The client is admitted to the ER with multiple rib fractures on the right. The nurse's assessment reveals that an area over the right clavicle is puffy and that there is a 'crackling' noise with palpation. The nurse should further assess the client for which of the following problems?
- A. Flail chest
- B. Subcutaneous emphysema
- C. Infiltrated subclavian IV
- D. Pneumothorax
Correct Answer: B
Rationale: The 'puffy' area and 'crackling' noise (crepitus) with palpation are classic signs of subcutaneous emphysema, where air is trapped under the skin, often due to a pneumothorax or rib fractures allowing air to escape into subcutaneous tissue.
Which instruction would not be included in the discharge teaching of the client receiving chlorpromazine (Thorazine)?
- A. You will need to wear protective clothing or a sunscreen when you are outside.'
- B. You will need to avoid eating aged cheese.'
- C. You should carry hard candy with you to decrease dryness of the mouth.'
- D. You should report a sore throat immediately.'
Correct Answer: B
Rationale: Avoiding aged cheese is relevant for MAO inhibitors, not chlorpromazine, which does not interact with tyramine-containing foods.
A client has increasing pain in both hands. On examination, the nurse notes that the metacarpophalangeal and proximal interphalangeal joints are enlarged and swollen, swanneck deformity is evident, and the fingers on both hands show ulnar deviation. These findings are consistent with which of the following disorders?
- A. Osteoarthritis
- B. Rheumatoid arthritis
- C. Gouty arthritis
- D. Psoriatic arthritis
Correct Answer: B
Rationale: Swanneck deformity, ulnar deviation, and swollen MCP/PIP joints are classic for rheumatoid arthritis (B). Osteoarthritis (A) affects distal joints, gout (C) causes tophi, and psoriatic arthritis (D) involves skin lesions.
Vitamin K is administered to the newborn shortly after birth for which of the following reasons?
- A. To stop hemorrhage
- B. To treat infection
- C. To replace electrolytes
- D. To facilitate clotting
Correct Answer: D
Rationale: Vitamin K is given to newborns to facilitate clotting, preventing hemorrhagic disease due to low vitamin K levels.