Nokea
The nurse observes a fire in a client's room. The nurse should take which initial action?
- A. Rescue the client
- B. Extinguish the fire
- C. Activate the fire alarm
- D. Place a linen blanket over the fire
Correct Answer: A
Rationale: Per the RACE protocol, rescuing the client is the initial action to ensure safety.
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The following scenario applies to the next 6 items
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 2 of 6
Nurses' Note
Current Medications
1349: Initial home visit performed. The client was hospitalized last week for four days following a ground-level fall, delirium, and cystitis. The client is alert and fully oriented. Clear lung sounds bilaterally. Peripheral pulses 2+. Her muscle movements were uncoordinated as she missed grabbing the television remote and a can of cola. Speech was intelligible with some pauses. When ambulating to the bathroom, she used scattered furniture as assistive devices. Skin is warm, dry, and normal for ethnicity. She reports significant fatigue throughout the day. She states that during the day, the heat bothers her, so she is reluctant to go to the mailbox. She is also tired while cooking and cleaning in the evening hours. Since discharge, the client reports that she sleeps 7-8 hours, but does not feel rested in the morning. She reports that her urine is clear and without odor, but she has an urgency when going to the bathroom. She reports numbness and tingling in the lower extremities that last all day. She does report her legs 'stiffening up' intermittently throughout the day. She reports that she is taking the prescribed antibiotic when she remembers. Denies any loss of appetite and has increased her fluids with cola and sweet tea since discharge.
The nurse reviews the assessment data and analyzes the individual's risk for falling. Click to specify whether each assessment finding is a risk factor for falling or not.
- A. Ambulation pattern
- B. Speech pattern
- C. Age
- D. Gender
- E. Fall history
- F. Current medications
Correct Answer: A,C,E,F
Rationale: Ambulation pattern, age (older adults), fall history, and medications (e.g., diazepam) are fall risk factors. Speech pattern and gender are not direct risk factors.
The nurse is caring for a postoperative client who is ordered to use an incentive spirometer. The nurse understands that this device will help prevent which complication?
- A. venous thromboembolism
- B. obstructive sleep apnea
- C. hypostatic pneumonia
- D. aspiration pneumonia
Correct Answer: C
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis, reducing the risk of hypostatic pneumonia in postoperative clients with limited mobility. It does not directly prevent venous thromboembolism, obstructive sleep apnea, or aspiration pneumonia.
The nurse is reviewing the laboratory results of a client scheduled for surgery. Which of the following should be reported to the primary health care provider (PHCP)?
- A. Glycosylated hemoglobin (HbA1c) of 7.2% [5.7-6.4%]
- B. International Normalized Ratio (INR) of 3.5 [0.9-1.2 seconds]
- C. Hematocrit (Hct) of 42% [Male: 42-52% Female: 37-47%]
- D. Blood urea nitrogen (BUN) level of 5 [10-20 mg/dL]
Correct Answer: B
Rationale: An INR of 3.5 indicates a high bleeding risk, critical for surgical safety, and must be reported to the PHCP. Elevated HbA1c, normal hematocrit, and low BUN are less urgent but may still require attention.
The nurse is discussing negligence with a new nurse. Which of the following situations can the nurse use as an example of negligence?
- A. The Unlicensed Assistive Personnel (UAP) fills a water basin with warm water while the client with depression combs their hair.
- B. A nurse transcribes a new medication order: Cholestyramine powder 2 oz bid with wet food or one full glass of water.
- C. The nurse first checks the distal pulses of a client's legs two hours after they have returned from a cardiac catheterization.
- D. The nurse observes a UAP enter the room of a client on contact precautions wearing gloves and a gown.
Correct Answer: NONE
Rationale: None of the options describe negligence, as all reflect appropriate actions or minor procedural variations without harm.
The nurse is caring for a client with an indwelling urinary catheter connected to a drainage bag. The nurse demonstrates effective care when. Select all that apply.
- A. Emptying the drainage bag when it is half full.
- B. Collecting a urine specimen for culture from the port in drainage tubing.
- C. Clamping the urinary catheter tubing prior to discontinuation.
- D. Instructing the client to carry the collection bag above their bladder during ambulation.
- E. The tubing goes in and out of the urethra during cleaning.
Correct Answer: A,B
Rationale: Emptying when half full prevents reflux, and collecting from the port ensures sterility. Clamping is unnecessary, carrying above the bladder risks reflux, and tubing movement risks infection.