Nokea
The nurse plans care for a client immediately post-operative. The nurse should initially assess the client's
- A. respiratory status
- B. tolerance to by-mouth (PO) fluids
- C. pain level
- D. ability to move the extremities
Correct Answer: A
Rationale: Respiratory status is the priority assessment post-operatively to ensure airway patency and adequate oxygenation, following the ABCs (airway, breathing, circulation) of care. Pain, fluid tolerance, and extremity movement are important but secondary to ensuring respiratory stability.
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The nurse is planning a staff development conference about ways to prevent the transmission of the hepatitis C virus to healthcare workers. It would be appropriate for the nurse to cover which topic?
- A. How to obtain the HCV vaccine
- B. How to dispose of sharps safely
- C. How to dispose of urine and feces for those with HCV
- D. Isolation precautions for individuals with HCV
Correct Answer: B
Rationale: Safe sharps disposal prevents needlestick injuries, a primary transmission route for HCV. No vaccine exists, and urine/feces disposal or isolation are less relevant.
The nurse is preparing to don sterile gloves. Which action should the nurse take to avoid contamination?
- A. Keep the hands above waist level.
- B. Select gloves that are one size larger than usual.
- C. Put on a sterile gown before donning the gloves.
- D. Don the sterile glove on the non-dominant hand first.
Correct Answer: A
Rationale: Keeping hands above waist level prevents contamination of sterile gloves by contact with non-sterile surfaces.
The nurse is caring for a client who is describing pain on their hand as 'throbbing and sharp.' Which type of pain is the client experiencing based on this sensory description?
- A. Somatic pain
- B. Visceral pain
- C. Ischemic pain
- D. Neuropathic pain
Correct Answer: A
Rationale: Throbbing and sharp pain describe somatic pain, arising from skin or musculoskeletal tissue. Visceral pain is dull, ischemic pain is aching, and neuropathic pain is burning or tingling.
The nurse is caring for a client who has soft-limb wrist restraints applied. The highest priority for the nurse is to
- A. Provide the client with opportunities to discuss their feelings.
- B. Document the neurovascular assessments.
- C. Assess the client's mood and affect.
- D. Offer nutrition and hydration.
Correct Answer: B
Rationale: Neurovascular assessments ensure circulation and safety, the highest priority with restraints. Other actions are important but secondary.
Which interventions are appropriate for venous thromboembolism prophylaxis when caring for a nonambulatory client? Select all that apply.
- A. Floating both of the heels using a pillow
- B. Apply sequential compression devices to the lower extremities
- C. Encourage range of motion exercises in the lower extremities
- D. Apply compression hose to the lower extremities
- E. Administer enoxaparin subcutaneously, as prescribed
Correct Answer: B,C,D,E
Rationale: Sequential compression, ROM exercises, compression hose, and enoxaparin prevent VTE. Heel floating reduces pressure ulcers, not VTE.