Nokea
The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include? Select all that apply.
- A. Ensure the oxygen delivery system is at least 8 feet from any heat source
- B. Adjust the oxygen flow rate as needed to ease breathing.
- C. Take antibiotic medication with or without food.
- D. Decrease the steroid dose each day.
- E. Take antibiotics for 10 days.
- F. Store the oxygen cylinder wrench with the oxygen tank.
- G. Take steroid medication in the morning.
Correct Answer: A,E,F,G
Rationale: A: Safety precaution. E: Standard antibiotic duration. F: Accessibility for emergencies. G: Morning steroids reduce adrenal suppression.
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A charge nurse on a long-term care unit is working with an assistive personnel who states, 'I am tired of all the changes on this unit. If things don't improve soon, I'm requesting a transfer.' Which of the following responses should the charge nurse make?
- A. There has been too much complaining about these changes.
- B. Please, try to wait a little longer. Things will get better soon.
- C. So, you are upset about all of the recent changes on the unit?
- D. Why don't you just file a formal complaint with Human Resources?
Correct Answer: C
Rationale: Reflecting the AP's feelings encourages open communication.
A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Postpone the procedure until the staff contacts the guardian.
- B. Obtain consent from the client.
- C. Prepare the client for surgery with implied consent.
- D. Request that the provider sign the consent form.
Correct Answer: C
Rationale: In emergencies, implied consent is appropriate when the guardian is unavailable.
A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?
- A. Obtain verbal consent from the client.
- B. Witness the client's signature on a consent form.
- C. Check the medical record for the client's signature on a previous consent form.
- D. Have another nurse co-sign the client's consent
Correct Answer: B
Rationale: Witnessing the signature ensures informed consent is documented per protocol.
A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the specimen in a clean specimen cup.
- B. Clamp the catheter tubing below the needleless port.
- C. Clamp the catheter tubing for 60 min.
- D. Remove 45 mL of urine from the catheter with a syringe.
Correct Answer: B
Rationale: Clamping below the port allows fresh urine to collect for an accurate culture.
A nurse is reviewing the medical record of a client. Click to highlight below the findings that require immediate follow-up.
- A. Neurological: Alert and oriented to person, place, and time; deep tendon reflexes 4+
- B. Musculoskeletal: Generalized weakness with equal bilateral muscle strength and mild leg cramping
- C. Respiratory: Lungs clear
- D. Cardiovascular: Heart rate irregular, Heart rate 95/min
- E. Gastrointestinal: Bowel sounds hyperactive x 4 quadrants
Correct Answer: D
Rationale: An irregular heart rate (D) requires immediate follow-up due to potential arrhythmia risks.