Nokea
The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. What should the nurse do first?
- A. Administer nasal oxygen at a rate of 5 L/min
- B. Help the client to lie back down in the bed
- C. Quickly pivot the client to the chair and elevate the legs
- D. Check the client's blood pressure and pulse
Correct Answer: D
Rationale: Before assisting the client out of bed, the nurse should first assess the client's blood pressure and pulse. This assessment is crucial to determine the client's physiological stability and readiness for ambulation. It ensures the client's safety during the transfer and helps prevent any potential complications that may arise from getting out of bed. Administering oxygen, lying the client back down, or quickly moving the client to a chair without assessing vital signs can compromise the client's safety and may lead to adverse outcomes.
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The healthcare professional is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the healthcare professional include in this procedure?
- A. Dilute each of the medications with sterile water prior to administration.
- B. Mix the medications in one syringe before opening the feeding tube.
- C. Administer water between the doses of the two liquid medications.
- D. Withdraw any fluid from the tube before instilling each medication.
Correct Answer: C
Rationale: To maintain patency and ensure proper medication delivery, water should be instilled into the feeding tube between administering the two medications. This helps prevent clogging of the tube and ensures that both medications are delivered effectively without interference from remnants of the previous medication. Diluting the medications with sterile water before administration (choice A) is unnecessary and may alter the medication concentration. Mixing the medications in one syringe (choice B) could lead to interactions or chemical reactions between the medications. Withdrawing fluid from the tube before instilling each medication (choice D) is not required and may increase the risk of tube displacement or misplacement.
The healthcare provider is assessing a client with a diagnosis of pneumonia. Which assessment finding is most concerning?
- A. Coarse crackles in the lungs.
- B. Fever of 101.2°F (38.4°C).
- C. Productive cough with yellow sputum.
- D. Respiratory rate of 28 breaths per minute.
Correct Answer: D
Rationale: A respiratory rate of 28 breaths per minute (D) is most concerning because it indicates respiratory distress and requires immediate intervention. While coarse crackles (A), fever (B), and productive cough (C) are common findings in pneumonia, a high respiratory rate signifies a more severe condition that needs prompt attention to prevent respiratory failure. Monitoring the respiratory rate is crucial in assessing the severity of respiratory distress in pneumonia, as it can rapidly progress to respiratory failure if not managed promptly.
A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, 'I want to go outside now and smoke. It takes forever to get anything done here!' Which intervention is best for the nurse to implement?
- A. Encourage the client to use a nicotine patch.
- B. Reassure the client that it is almost time for another break.
- C. Have the client leave the unit with another staff member.
- D. Review the schedule of outdoor breaks with the client.
Correct Answer: D
Rationale: When a client becomes angry while waiting for a supervised break, it is essential to address their concerns effectively. Reviewing the schedule of outdoor breaks with the client provides concrete information, helps manage the client's expectations, and may alleviate their frustration. This intervention promotes transparency and empowers the client by clarifying the timing of their desired break, fostering a therapeutic and collaborative nurse-client relationship. Encouraging the client to use a nicotine patch (Choice A) does not address the client's immediate frustration with the break schedule. Reassuring the client about another break (Choice B) may temporarily placate them but does not address the underlying issue. Having the client leave the unit with another staff member (Choice C) may not be feasible or appropriate at that moment and does not address the client's concerns.
By rolling contaminated gloves inside-out, the healthcare professional is affecting which step in the chain of infection?
- A. Mode of transmission
- B. Portal of entry
- C. Reservoir
- D. Portal of exit
Correct Answer: A
Rationale: When contaminated gloves are rolled inside-out, they are serving as a mode of transmission by carrying pathogens from the reservoir's portal of exit to a new portal of entry. This action increases the risk of transmitting infections from one person to another, emphasizing the importance of proper glove removal techniques to prevent the spread of pathogens. Choices B, C, and D are incorrect in this context. Portal of entry refers to the route through which a pathogen enters a susceptible host, reservoir is the habitat where the pathogen lives, grows, and multiplies, and portal of exit is the path through which a pathogen leaves its host.
During the assessment, a client receiving a continuous infusion of heparin for deep vein thrombosis (DVT) is found to have a nosebleed. Which finding requires immediate action?
- A. The client's activated partial thromboplastin time (aPTT) is 70 seconds.
- B. The client has developed a nosebleed.
- C. The client's blood pressure is 150/90 mm Hg.
- D. The client reports feeling lightheaded.
Correct Answer: B
Rationale: A nosebleed (B) in a client receiving heparin is a sign of heparin toxicity and requires immediate action. It indicates that the client is at risk of excessive bleeding. While a prolonged aPTT of 70 seconds (A) is worth monitoring, active bleeding takes precedence. Elevated blood pressure (C) and lightheadedness (D) are potential side effects of heparin but are not as urgently concerning as active bleeding.