Nokea
The nurse is starting a peripheral vascular access device for a client. The nurse inserted the device into the vein and observed a flashback of blood in the chamber. The nurse should then
- A. Advance the VAD approximately 3 inches (7.62 cm) into the vein and loosen the stylet.
- B. Remove the stylet and secure the catheter using a transparent dressing.
- C. Advance the VAD approximately 1/4 inch (0.6 cm) into the vein and loosen the stylet.
- D. Remove the stylet and release the tourniquet.
Correct Answer: D
Rationale: After observing a blood flashback, the nurse should remove the stylet and release the tourniquet to prevent hematoma formation, then secure the catheter. Advancing further risks vein damage or dislodgement, and securing without releasing the tourniquet is incorrect.
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The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure?
- A. Nasogastric tube (NGT)
- B. Bottle of sterile water
- C. Suction equipment
- D. Tracheostomy
Correct Answer: C
Rationale: Cheiloplasty is a surgical repair of a cleft lip, which can affect the infant’s ability to feed and maintain a clear airway. Suction equipment is essential at the bedside to clear secretions or blood from the oral cavity, preventing airway obstruction and ensuring airway patency. A nasogastric tube is not typically required unless feeding difficulties are severe. Sterile water is not a priority for immediate postoperative care, and a tracheostomy is not indicated for this procedure.
The nurse provides discharge teaching to a client prescribed a cane for left-sided weakness. Which instruction should the nurse provide?
- A. Advance the cane along with your stronger leg.
- B. Remove the rubber tip when going upstairs.
- C. Measure the height of the cane to your elbow.
- D. Secure the cane in your right hand.
Correct Answer: D
Rationale: The cane is held in the right hand (stronger side) for left-sided weakness to support the weaker leg. The stronger leg moves first, rubber tips stay on, and height is measured to the greater trochanter.
The nurse is admitting a client diagnosed with hepatitis B. The nurse would be able to cohort the client in the same room with which of the following clients? A client with
- A. Heart failure receiving diuretics
- B. Bacterial meningitis receiving antibiotics
- C. Prostate cancer receiving brachytherapy
- D. Varicella prescribed antivirals
Correct Answer: A
Rationale: Hepatitis B is transmitted via blood/body fluids, so rooming with a heart failure client is safe. Meningitis, varicella, and brachytherapy require specific precautions or isolation.
The nurse is interviewing a 25-year-old female client who recently experienced domestic violence. What is the rationale for excluding the family from the interview to ensure a safe and confidential environment? Select all that apply.
- A. Promote client autonomy
- B. Maintain family dynamics and support
- C. Maintains privacy and confidentiality
- D. Prevent potential intimidation or coercion
- E. Minimize the risk of retaliation
Correct Answer: A,C,D,E
Rationale: Excluding family promotes autonomy, privacy, and prevents intimidation or retaliation. Maintaining family dynamics is not a priority in this context.
One of the complications associated with the improper use of crutches is:
- A. Axillary nerve damage
- B. Solar plexus nerve damage
- C. Carpal tunnel syndrome
- D. Trigeminal nerve damage
Correct Answer: A
Rationale: Improper crutch use can compress the axillary nerve, causing nerve damage. Other options are unrelated to crutches.