Nokea
The nurse is supervising a graduate nurse completing an incident report regarding a client who fell. Which of the following actions by the graduate nurse requires follow-up?
- A. Documents an objective description of what happened
- B. Indicates that a 2-inch laceration was present on the client's scalp
- C. Documents in the nursing note that an incident report was completed
- D. Indicates the follow-up actions taken
Correct Answer: C
Rationale: Documenting the incident report in the nursing note violates confidentiality; incident reports are separate from patient records.
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A nurse is caring for a client who has complete immobility and is bedbound. Which of the following complications should the nurse monitor for? Select all that apply.
- A. Peripheral neuropathy
- B. Increased peristalsis leading to diarrhea
- C. Joint contractures
- D. Increased bone density
- E. Peripheral edema
- F. Pneumonia
Correct Answer: C,E,F
Rationale: Immobility causes contractures, edema, and pneumonia due to reduced mobility and lung expansion. Neuropathy and increased peristalsis are unrelated, and bone density decreases.
The nurse is conducting a staff education program on managing chemotherapy spills. Which actions should the nurse recommend be taken in the event of a chemotherapy spill? Select all that apply.
- A. Contain the spill using plastic-backed absorbent sheets or spill pads.
- B. Wear sterile gloves when cleaning the spill.
- C. Immediately remove any contaminated clothing and wash the affected skin with soap and water.
- D. Research the appropriate cleaning agent based on the spilled drug.
- E. Leave the spill area unattended until a supervisor arrives.
- F. Implement airborne precautions after the spill has been cleaned.
Correct Answer: A,C
Rationale: Containing the spill and decontaminating skin/clothes are critical. Sterile gloves are unnecessary, researching during a spill delays action, leaving unattended is unsafe, and airborne precautions are irrelevant.
The nurse is preparing to insert a nasogastric tube (NGT). Which action should the nurse take?
- A. Rinse the tube with warm, soapy water
- B. Perform hand hygiene
- C. Don sterile gloves
- D. Obtain a computed tomography (CT) scan to verify placement
Correct Answer: B
Rationale: Hand hygiene is essential before NGT insertion to prevent infection. Rinsing with soapy water is incorrect, clean gloves suffice, and CT is not used for verification.
The nurse assists a client with left-sided weakness. Which of the following actions should the nurse perform when assisting this client in ambulating with a cane? Select all that apply.
- A. Place a gait belt around the client's waist.
- B. Stand on the client's left side during ambulation.
- C. Instruct the client to put the cane in the left hand.
- D. Measure the cane from the client's wrist crease.
- E. Instruct the client to put the cane in the right hand.
- F. Instruct the client to look down while ambulating.
Correct Answer: A,B,E
Rationale: A gait belt ensures safety, standing on the weaker side provides support, and the cane in the right hand aids balance. Cane height is measured to the greater trochanter, and looking down risks falls.
The nurse plans to care for a client admitted with Haemophilus influenzae, type b Meningitis. When caring for this client, the nurse should gather which appropriate personal protective equipment (PPE)?
- A. boot (shoe) covers
- B. face shield
- C. surgical mask
- D. gown
Correct Answer: C
Rationale: Haemophilus influenzae, type b meningitis requires droplet precautions, which include wearing a surgical mask when within 3 feet of the client. Boot covers, face shields, and gowns are not specifically required unless additional risks (e.g., splashing) are present.