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The nurse plans to use a mechanical lift to transfer a client from a stretcher to a wheelchair. Which appropriate action should the nurse take?
- A. Keep the stretcher's side rails raised during the transfer
- B. Instruct the client to fold their arms over their chest
- C. Apply gloves and gown for this procedure
- D. Unlock the wheels on the stretcher and wheelchair
Correct Answer: B
Rationale: Instructing the client to fold their arms over their chest prevents interference with the lift and ensures safety. Side rails should be down, gloves/gown are not required, and wheels should be locked.
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The nurse observes a client perform isometric exercises. It would indicate effective understanding if the client
- A. Exercises both extremities simultaneously.
- B. Knows their heart rate should be monitored while exercising.
- C. Practices forced resistance against stable objects.
- D. Swings their limbs through the full range of motion.
Correct Answer: C
Rationale: Isometric exercises involve static muscle contraction against resistance, like pushing against a stable object. Simultaneous exercise, heart rate monitoring, and full range of motion are not specific to isometrics.
The nurse is preparing to obtain a capillary blood glucose from a client. Place the following actions in the order in which they should be performed, starting from first to last.
- A. Hold the gauze on the client's finger after the specimen has been obtained.
- B. Turn the finger down to promote blood flow with gravity.
- C. Insert strip into monitor.
- D. Prick the side of the finger using the lancet.
- E. Verify and confirm that the code strip corresponds to the meter code.
- F. Disinfect the client's finger with an alcohol swab and allow it to dry.
- G. Read the client's blood glucose level on the monitor.
Correct Answer: E,F,C,D,B,A,G
Rationale: The correct order is: verify strip code (E), disinfect finger (F), insert strip (C), prick finger (D), promote blood flow (B), collect sample and apply gauze (A), read result (G). This ensures accuracy and safety.
Item 1 of 1
• Nurses' Notes
0920: Client presents for a follow-up visit. Client reports increased difficulty with activities of daily living because of dyspnea. Reports pain and swelling in both lower extremities that increases with movement. "Washing my hair now takes me an hour instead of fifteen minutes." Transverse surgical incision was pink, approximated, and crusted—9 inches in length. Two Jackson-Pratt drains contained a total of 15 mL of serumlike drainage. Incisional pain reported at a '4' on the Numerical Rating Scale. Endorses increased incisional pain while coughing. The client reports full adherence to postoperative enoxaparin self-injections. She reports ejecting the air bubble prior to injection. Reports relief with prescribed oxycodone-acetaminophen but experiences generalized itching and drowsiness after.
• Medical History
• gastric bypass surgery performed two years ago
• dyslipidemia
• diabetes mellitus (type two)
• Vital Signs
• T 99.0°F (37.2°C); HR 90 beats/min; RR 18 breaths/min; BP 119/67 mm Hg; Pulse oximetry 96% on room air.
The nurse in the medical office is caring for a 41-year-old client who is 2-week postoperative abdominoplasty. Which of the following assessment findings require immediate follow-up? Select all that apply.
- A. wound assessment findings
- B. tolerance with activities of daily living
- C. pain in lower extremities
- D. enoxaparin self-injections
- E. pulse, respirations, and blood pressure
Correct Answer: B,C,D
Rationale: Tolerance with activities of daily living. The client reports increased difficulty with activities of daily living (ADLs) due to dyspnea, which could indicate a significant complication, such as pulmonary embolism (PE). Dyspnea, especially in the postoperative period, should always be investigated promptly, as it could be a sign of a PE, which is a life-threatening emergency. Immediate follow-up is necessary to rule out PE or other respiratory or circulatory issues. Pain in lower extremities. Pain and swelling in the lower extremities that increase with movement could suggest deep vein thrombosis (DVT). This complication is especially concerning in a postoperative patient on anticoagulation therapy (enoxaparin). DVT can lead to pulmonary embolism if the clot dislodges, which could cause dyspnea. This requires immediate follow-up to assess for DVT and initiate treatment if necessary. The client reports full adherence to postoperative enoxaparin self-injections and mentions ejecting the air bubble before injection. This is an incorrect technique; ejecting the air bubble can result in an underdose of the medication, potentially leading to ineffective anticoagulation. This can increase the risk of complications like DVT or VTE. Correct technique is crucial to ensure proper dosing. Immediate follow-up is required to educate the client about appropriate injection techniques (not ejecting the air bubble) to prevent these risks.Wound assessment findings. The transverse surgical incision is described as pink, approximated, and crusted, which are normal findings in the early postoperative period. These findings suggest no signs of infection or delayed wound healing. Therefore, no immediate follow-up is required for this finding.Incision pain level and characteristics. The client reports incisional pain at a level of 4 on the Numerical Rating Scale and increased pain when coughing. This level of pain is within a manageable range for a postoperative patient. The description of the pain as incisional and aggravated by coughing is consistent with expected postoperative discomfort. The pain level is manageable, and this is not a priority concern for immediate follow-up unless it becomes severe or is associated with other complications (e.g., infection or dehiscence).
The nurse is teaching a parenting class on infant car seat safety. Which statements should the nurse include? Select all that apply.
- A. Place the car seat rear-facing in the back seat and at 90 degrees.
- B. The car seat straps should fit snugly over the shoulders.
- C. Infants should ride in a car seat, rear-facing, in the back seat, until six months.
- D. Rolled blankets may be needed between the crotch and legs to prevent slouching.
- E. You may add padding underneath the infant to increase their comfort.
Correct Answer: B,D
Rationale: Snug straps and rolled blankets for positioning are correct. Rear-facing should be until at least 2 years, not 90 degrees, and padding underneath is unsafe.
The emergency department (ED) charge nurse is preparing for a surge of clients diagnosed with Ebola virus disease (EVD). The nurse should plan to take which action? Select all that apply.
- A. Implement visitor restrictions for affected clients
- B. Log entry and exit of all healthcare workers who provide care
- C. Ensure that bleach disinfectant wipes are available in each room
- D. Provide reusable personal protective equipment
- E. Have an observer for donning and doffing of personal protective equipment
Correct Answer: A,B,E
Rationale: Visitor restrictions, logging healthcare worker movements, and an observer for PPE donning/doffing are critical for EVD control. Bleach wipes are insufficient, and reusable PPE is not recommended.