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The nurse is reviewing the labs of a child who has recently had oral surgery. Which of the following lab results should the nurse pay the closest attention to?
- A. BUN level
- B. Prothrombin time
- C. Creatinine level
- D. Viral load
Correct Answer: B
Rationale: Prothrombin time assesses clotting, critical post-oral surgery to monitor bleeding risk. BUN and creatinine assess kidney function, and viral load is irrelevant.
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The nurse cares for a client with a double-lumen peripherally inserted central catheter (PICC). Which of the following actions would be appropriate for the nurse to take?
- A. Assign the client to a private room.
- B. Change the dressing daily using sterile technique.
- C. Flush heparin prior to discontinuation.
- D. Aspirate each lumen for blood return and then flush.
Correct Answer: D
Rationale: Aspirating for blood return and flushing ensures PICC patency. Private rooms, daily dressing changes, and heparin flushing are not standard unless specified.
The nurse is caring for a group of premature infants. Which action is most important in preventing healthcare-acquired infection?
- A. Performing frequent hand hygiene
- B. Disinfecting commonly touched surfaces
- C. Screening visitors for illness
- D. Administer prophylactic antibiotics
Correct Answer: A
Rationale: Frequent hand hygiene is the most effective measure to prevent healthcare-acquired infections in vulnerable populations like premature infants.
Which of the following children would the nurse identify as a priority for having the greatest risk for choking and suffocating?
- A. A toddler playing with his 9-year-old brother's construction set.
- B. A 5-year-old eating yogurt for a snack.
- C. An infant asleep in her crib without a blanket.
- D. A 3-year-old drinking a glass of juice.
Correct Answer: A
Rationale: A toddler playing with small construction set pieces is at high risk for choking due to the size and accessibility of the objects.
The nurse has attended a conference on intraoperative nursing interventions for the older adult. which of the following statements by the nurse would indicate the need for additional teaching?
- A. Warming devices should be used to prevent the client from developing hypothermia
- B. The client's head and feet should be covered during surgery
- C. Clients should be slid, not lifted into the proper position
- D. Providing extra padding for clients with decreased peripheral circulation is important
Correct Answer: C
Rationale: Sliding clients instead of lifting can cause shear injuries, particularly in older adults with fragile skin. Warming devices, covering extremities, and extra padding are appropriate to prevent hypothermia and protect pressure points, indicating correct understanding.
The nurse has attended a continuing education conference focused on reducing work-related injuries. Which statement by the nurse would require follow-up regarding actions helpful in reducing work-related injuries?
- A. Keeping back, neck, pelvis, and feet aligned helps maintain proper posture and reduces strain.
- B. I should position myself furthest away from the client (or object) being lifted.
- C. Flexing the knees and maintaining a broad base of support provides stability and helps distribute weight evenly.
- D. Encouraging the client to assist during repositioning or transfers promotes independence and reduces strain on the caregiver.
Correct Answer: B
Rationale: Positioning close to the client reduces strain during lifting. Other statements promote proper body mechanics.