Nokea
The nurse prepares to insert a peripheral vascular access device (PVAD) in the client's cephalic vein. The nurse plans to align the catheter how many degrees above the targeted vein?
- A. 10-30 degrees
- B. 30-45 degrees
- C. 45-90 degrees
- D. 45-60 degrees
Correct Answer: A
Rationale: A 10-30 degree angle is optimal for PVAD insertion to enter the vein without piercing through it. Higher angles increase the risk of vein perforation or improper placement.
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The nurse teaches a client scheduled for an upcoming total hip arthroplasty. Which of the following statements by the client would require follow-up?
- A. I will need to bathe with chlorhexidine gluconate solution (CHG) the night before surgery to prevent an infection
- B. I will need to take deep breaths and cough hourly
- C. I will have to attend physical therapy sessions following my surgery
- D. I will be prescribed an anticoagulant and need to take it with a sip of water before the surgery
Correct Answer: D
Rationale: Taking an anticoagulant with a sip of water before surgery is incorrect, as clients are typically NPO, and anticoagulants like enoxaparin are administered post-operatively to prevent thromboembolism. The other statements are correct regarding infection prevention, respiratory exercises, and physical therapy.
The nurse is observing a student collect vital signs on a client. Which action by the student requires the nurse to intervene? Select all that apply.
- A. Obtains the blood pressure with a cuff bladder width of at least 40% of arm circumference.
- B. Places the BP cuff over the client's clothing garment.
- C. Requests the client remove their hearing aid before obtaining a tympanic temperature.
- D. Assesses the client's respirations after obtaining the pulse rate.
- E. Obtains blood pressure by placing the client's upper extremity at the level of their heart.
- F. Places the pulse oximeter probe on the client's finger that has edema.
Correct Answer: B,F
Rationale: Placing the BP cuff over clothing and using an edematous finger for pulse oximetry can yield inaccurate readings. Other actions are correct.
Item 1 of 1 • Assessment
Neurological: Alert and Oriented x 4; anxious affect
Cardiovascular: S1, S2 heart tones; all peripheral pulses palpable; no edema
Gastrointestinal: Distended abdomen; absent bowel sounds; hiccups; reports persistent nausea
Genitourinary: Denies dysuria; voiding every 3-4 hours with straw-colored urine
Musculoskeletal: Full range of motion in all extremities; steady gait
Integumentary: Incision is approximated; moderate dry sanguineous drainage was noted on the dressing.
Pain: Reports incision pain as a 3 based on a scale of 0-10.
• Vital Signs
Blood Pressure 119/75 mm Hg
Temperature 99° F (37° C)
Heart rate 90/min
Respiratory rate 17 breaths per minute
Oxygen saturation 97% on room air
The nurse is caring for a client two days postoperative following a partial colectomy.Complete the sentence below from the list of options: The client is at risk of developing
--------------based on the client’s------------------------
- A. paralytic ileus
- B. wound infection
- C. intractable pain
- D. integumentary assessment
- E. pain assessment
- F. gastrointestinal assessment
Correct Answer: A,F
Rationale: The client exhibits signs of paralytic ileus, as evidenced by the gastrointestinal assessment findings (distended abdomen, absent bowel sounds, nausea, and hiccups).
The clinical data do not support wound infection as it is too early in the postoperative period for this to occur, and the client has no other manifestations supporting this finding.
Pain is expected in the postoperative period, and the current pain rating is mild-to-moderate (3). In contrast, intractable pain would be suggested by pain not relieved by medication and at a severe level.
The infection control nurse is responding to an outbreak of norovirus in the facility. The nurse should recommend that
- A. staff wears a surgical mask when providing client care.
- B. disposable utensils and dishware are used for meals.
- C. dietary staff wears a face shield when preparing client meals.
- D. commonly touched surfaces be disinfected with a bleach solution.
Correct Answer: D
Rationale: Norovirus requires contact precautions, including bleach disinfection of surfaces. Masks, disposable utensils, and face shields are not standard.
The nurse is caring for a post-operative client at risk for a pressure ulcer. Which intervention should the nurse include in the plan of care?
- A. Apply sequential compression devices
- B. Apply an extra sheet to the bed
- C. Position the client on a donut pillow
- D. Encourage the consumption of high-protein foods
Correct Answer: D
Rationale: High-protein foods support tissue repair and collagen synthesis, critical for preventing pressure ulcers in at-risk clients. Sequential compression devices prevent thromboembolism, not pressure ulcers. An extra sheet does not reduce pressure, and donut pillows can increase pressure on surrounding tissues, worsening the risk.