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The nurse is supervising a student assisting a client with their newly prescribed crutches. Which action by the student requires follow-up by the nurse? The student
- A. Positions the handgrips so that the axillae support the client's body weight.
- B. Demonstrates the proper crutch stance at 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot.
- C. Observes two to three finger widths between the crutch pad and the client's axilla.
- D. Instructs the client to dry crutch tips with a paper towel if they become wet.
Correct Answer: A
Rationale: Axillary weight-bearing risks nerve damage; weight should be on hands. Proper stance, axilla gap, and drying tips are correct.
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The occupational health nurse assesses a health care worker's purified protein derivative (PPD) test and measures 11 mm of induration. The nurse should interpret this finding as
- A. A confirmatory test result for pulmonary tuberculosis.
- B. A false-negative test result.
- C. The healthcare worker requires immediate isolation using airborne isolation precautions.
- D. Further testing is required.
Correct Answer: D
Rationale: An 11 mm induration in a healthcare worker indicates a positive PPD test, suggesting TB exposure, but further testing (e.g., chest X-ray, sputum analysis) is needed to confirm active TB. It is not confirmatory for pulmonary TB, not false-negative, and isolation is premature.
The nurse observes a patient walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Which of the following should the nurse assess in the patient?
- A. Pain
- B. Anxiety
- C. Depression
- D. Fluid volume deficit
Correct Answer: A
Rationale: Stooped gait, grimacing, and gasping suggest pain, requiring immediate assessment. Anxiety, depression, or fluid deficit are less likely based on these signs.
While starting a peripheral vascular access device (VAD) on a client, the nurse suffers a needlestick injury. Which action should the nurse take?
- A. Ask the client if they have the hepatitis A virus.
- B. Wash the affected extremity with soap and water.
- C. Document the incident in the client's medical record.
- D. Discontinue the vascular access device.
Correct Answer: B
Rationale: Washing with soap and water is the initial action to reduce infection risk after a needlestick.
Your client is reluctant to take a necessary dose of narcotic analgesic for severe pain. The client states, 'I do not want to become a druggie.' How would you respond to this client's comment?
- A. That is ridiculous. Nobody gets addicted to narcotics when they do not have a prior history of drug abuse.
- B. The possible complications of unrelieved pain greatly outweigh the risk of addiction which is very low when a person has no prior history of drug abuse.
- C. A lot of people prefer to be brave and stick it out so you are not alone.
- D. You have a right to refuse any and all treatments, so just do without it.
Correct Answer: B
Rationale: Addressing pain complications and reassuring low addiction risk educates and encourages treatment. Dismissing concerns, normalizing endurance, or supporting refusal are non-therapeutic.
The nurse reviews a client’s laboratory data before a scheduled surgery. Which laboratory data requires immediate follow-up?
- A. Sodium level
- B. Potassium level
- C. Blood Urea Nitrogen (BUN)
- D. Creatinine
Correct Answer: B
Rationale: Abnormal potassium levels can cause cardiac arrhythmias, a critical risk during surgery, requiring immediate follow-up. Sodium, BUN, and creatinine abnormalities are less immediately life-threatening but still important.