Nokea
The nurse observes that a fire has ignited in the client's room. After removing the client from the room, the nurse should then
- A. activate the fire alarm.
- B. extinguish the fire.
- C. contact the nursing supervisor.
- D. close the door to the client's room.
Correct Answer: A
Rationale: Following the RACE protocol (Rescue, Alarm, Contain, Extinguish), after rescuing the client, the nurse should activate the fire alarm to alert others and initiate emergency response.
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The nurse is performing an initial home health visit on a client who had a stroke one week ago with left-sided hemiparesis. Select the findings in the admission note that require follow-up.
- A. Affect was flat, and the client appeared withdrawn
- B. The client reported full adherence to their prescribed medications
- C. The client reported that they missed two physical therapy appointments.
- D. The client reported that they removed the cane's rubber tip because it left marks on their flooring.
- E. The client ambulated with the cane and held it in their right hand.
- F. The client advanced the cane 12-14 inches (30-36 cm) with each step
Correct Answer: A,C,D
Rationale: Flat affect, missed therapy, and removed rubber tip indicate depression, non-adherence, and safety risks, needing follow-up. Medication adherence, correct cane use, and proper advancement are appropriate.
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 is caring for a client with a tracheostomy who requires suctioning. Which of the following actions by the nurse would indicate correct technique?
- A. Using a size 16 Fr catheter to suction the client.
- B. Withdrawing the suction catheter 1 to 2 cm before applying suction.
- C. Using 160 mm Hg of pressure when suctioning the client.
- D. Applying suction to the catheter for 25 seconds during withdrawal.
Correct Answer: B
Rationale: Withdrawing the catheter 1-2 cm before suctioning prevents mucosal trauma. A 16 Fr catheter may be too large, 160 mm Hg is excessive (80-120 mm Hg is typical), and suctioning for 25 seconds is too long (≤10-15 seconds).
The nurse is teaching a client about a vegan diet. Which of the following foods should the nurse recommend for this diet? Select all that apply.
- A. Legumes
- B. Tofu
- C. Almonds
- D. Prunes
- E. Baked fish
- F. Grapefruit
Correct Answer: A,B,C,D,F
Rationale: Vegan diets exclude animal products, so legumes, tofu, almonds, prunes, and grapefruit are suitable. Baked fish is not vegan.
The nurse is caring for an older adult following a total hip arthroplasty. The nurse should anticipate a prescription for which postoperative medication?
- A. Hydrocortisone
- B. Enoxaparin
- C. Metoprolol
- D. Furosemide
- E. Morphine
Correct Answer: B,E
Rationale: Enoxaparin prevents venous thromboembolism, a common risk post-hip arthroplasty, and morphine manages postoperative pain. Hydrocortisone, metoprolol, and furosemide are not routinely prescribed unless indicated by specific conditions.