Nokea
The nurse is prioritizing caring for four assigned clients. Based on the pulse (P), respiratory rate (R), and blood pressure (BP) provided, which of the clients should the nurse follow up with first?
- A. P: 109; R: 26; BP: 110/70 mmHg
- B. P: 90; R: 12; BP: 99/54 mmHg
- C. P: 100; R: 18; BP: 161/98 mmHg
- D. P: 88; R: 14; BP: 166/52 mmHg
Correct Answer: B
Rationale: BP 99/54 mmHg indicates hypotension, requiring immediate follow-up. Tachycardia/tachypnea, hypertension, and wide pulse pressure are concerning but less urgent.
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The nurse is assessing a client's peripheral vascular access device. The assessment shows that the site is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. Which of the following complications is the client experiencing?
- A. Occlusion
- B. Infiltration
- C. Phlebitis
- D. Air embolism
Correct Answer: C
Rationale: Redness, warmth, pain, and edema indicate phlebitis, vein inflammation. Occlusion blocks flow, infiltration involves fluid leakage, and air embolism is unrelated.
The nurse is participating in a committee changing the hospital security plan. Which of the following statements by the nurse would be appropriate to make? Select all that apply.
- A. Open visitation should be implemented in the newborn nursery.
- B. Visitors should always wear a badge while in the hospital
- C. Oral temperatures should be obtained for all visitors
- D. Hand sanitizing stations should be offered throughout the facility
- E. Disaster drills should be conducted to ensure staff competency
Correct Answer: B,D,E
Rationale: Visitor badges, hand sanitizing stations, and disaster drills enhance security. Open visitation in nurseries and visitor temperature checks are impractical or unsafe.
The nurse is part of an infection control committee that is responding to an outbreak of norovirus in the long-term care facility. Which recommendation should the nurse make to prevent further transmission of this outbreak?
- A. Place face shields outside client rooms.
- B. Discontinue indwelling urinary catheters that are not medically necessary.
- C. Wipe down surfaces with hot, soapy water.
- D. Increase the frequency of cleaning and disinfection of client care areas.
Correct Answer: D
Rationale: Increased cleaning and disinfection of surfaces prevent norovirus spread via contaminated surfaces. Face shields, catheter discontinuation, and soapy water are less effective.
The nurse is observing a student nurse feed a client requiring aspiration precautions. The nurse should intervene if the student
- A. Asks the client to remain sitting upright for at least 30 to 60 minutes after a meal.
- B. Reminds the client to tilt their head backward when eating and drinking.
- C. Avoids mixing foods of different textures in the same mouthful.
- D. Places salt and pepper on the client's food at their request.
Correct Answer: B
Rationale: Tilting the head backward increases aspiration risk. Upright positioning, avoiding mixed textures, and seasoning food are appropriate.
The occupational health nurse is teaching a group of unlicensed assistive personnel how to practice appropriate ergonomics. It would be appropriate for the nurse to recommend that
- A. your feet are firmly on the floor while you are sitting in a chair
- B. Your feet are close together as you move or transfer a client.
- C. heavy objects are held far away from your body to achieve balance.
- D. you should squat to lift objects off of the ground.
- E. your neck should be extended as you look at the computer monitor.
Correct Answer: A,D
Rationale: Feet on the floor and squatting to lift reduce strain. A wide stance, holding objects close, and neutral neck position are correct ergonomic practices.