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While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion (CPM) device. Which of the following actions should the nurse take first?
- A. Initiate a requisition for a replacement CPM device.
- B. Report the defect to the equipment maintenance staff.
- C. Remove the device from the room.
- D. Ensure the device inspection sticker is current.
Correct Answer: C
Rationale: The correct action the nurse should take first is to remove the device from the room (Choice C). This is crucial because a frayed electrical cord poses a significant safety risk, potentially leading to electric shock or fire hazard. By removing the device from the room, the nurse ensures that the client and others are not exposed to the danger posed by the damaged cord. Initiating a requisition for a replacement device (Choice A) can be done after ensuring immediate safety. Reporting the defect to equipment maintenance staff (Choice B) is important, but it is secondary to removing the device from the room. Ensuring the device inspection sticker is current (Choice D) is not the priority when there is a clear safety issue present.
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A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning.
- A. Rinse the catheter to remove secretions.
- B. Insert the catheter during the client's inspiration.
- C. Turn on the suction and set the pressure.
- D. Don sterile gloves
- E. Apply sunction while rotating catheter
Correct Answer: D,C,B,E,A
Rationale: Correct Order: D, C, B, E, A
Rationale:
1. Don sterile gloves (D): Ensures infection control and prevents cross-contamination.
2. Turn on suction and set pressure (C): Prepares equipment and ensures proper functioning.
3. Insert catheter during client's inspiration (B): Reduces risk of inducing hypoxia.
4. Apply suction while rotating catheter (E): Maximizes removal of secretions.
5. Rinse catheter to remove secretions (A): Ensures cleanliness and prevents re-introduction of secretions.
Summary of Incorrect Choices:
- F and G are not applicable in this sequence.
- Inserting the catheter during inspiration (B) is correct, not during expiration.
- Rinsing the catheter (A) is done after suctioning, not before.
A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?
- A. Fidelity
- B. Veracity
- C. Autonomy
- D. Beneficence
Correct Answer: D
Rationale: The correct answer is D: Beneficence. Beneficence is the ethical principle of doing good or promoting the well-being of others. By sitting with the client to provide comfort after the loss of their partner, the nurse is demonstrating beneficence by actively seeking to alleviate the client's suffering and promoting their emotional well-being.
Rationale for why the other choices are incorrect:
A: Fidelity relates to the nurse's obligation to be faithful and keep promises made to the client, which is not directly demonstrated in this scenario.
B: Veracity is the principle of truthfulness, which is not the primary focus of the nurse's actions in this situation.
C: Autonomy refers to respecting the client's right to make their own decisions, which is not the main principle being demonstrated when the nurse is providing comfort and support.
E, F, G: These choices are not provided, but based on the context of the scenario, they are not relevant to the nurse's actions in providing comfort
A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
- A. A client who is scheduled for a procedure in 1 hr.
- B. A client who received a pain medication 30 min ago for postoperative pain.
- C. A client who was just given a glass of orange juice for a low blood glucose level.
- D. A client who has 100 mL of fluid remaining in his IV bag.
Correct Answer: C
Rationale: The nurse should assess client C first because low blood glucose levels can lead to serious complications if not addressed promptly. Hypoglycemia can result in altered mental status, seizures, and even coma. Assessing and addressing this client's low blood glucose level is a priority to prevent further deterioration.
Clients A, B, and D do not have immediate life-threatening conditions that require urgent assessment compared to client C. Client A, scheduled for a procedure in 1 hr, can be assessed after client C. Client B, who received pain medication 30 min ago, would have some time before needing reassessment. Client D, with 100 mL of fluid remaining in the IV bag, can also wait as long as there is no indication of the client being dehydrated or in need of immediate intervention.
A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take?
- A. Position the client on the affected side for 4 hr following the procedure.
- B. Instruct the client to avoid coughing during the procedure.
- C. Inform the client that he will be NPO for 6 hr prior to the procedure.
- D. Place the client in the prone position during the procedure.
Correct Answer: B
Rationale: Correct Answer: B - Instruct the client to avoid coughing during the procedure.
Rationale: Coughing during thoracentesis can increase the risk of complications such as lung puncture or bleeding. Instructing the client to avoid coughing helps maintain safety during the procedure by minimizing these risks.
Incorrect Choices:
A: Positioning the client on the affected side for 4 hours following the procedure is not necessary and may not be beneficial. It does not directly impact the safety or success of the thoracentesis.
C: NPO for 6 hours prior to the procedure is not typically required for a thoracentesis. This action is more common for procedures involving anesthesia or sedation.
D: Placing the client in the prone position during the procedure is not recommended for thoracentesis. The client is usually positioned upright or slightly leaning forward to facilitate the procedure.
A nurse is assessing a client immediately following a cardiac catheterization. The nurse should notify the provider for which of the following findings?
- A. Report of discomfort at the insertion site
- B. Heart rate 90/min
- C. Bounding pulses in the affected extremity
- D. Hematoma over the insertion site
Correct Answer: C
Rationale: The correct answer is C: Bounding pulses in the affected extremity. Bounding pulses can indicate arterial occlusion or other circulatory complications post-cardiac catheterization, requiring immediate intervention. A: Discomfort at the insertion site is expected and can be managed with pain medication. B: Heart rate of 90/min is within normal range. D: Hematoma over the insertion site is common after the procedure and may resolve on its own.