Nokea
The nurse reviews a client’s laboratory data before a scheduled surgery. Which laboratory data requires immediate follow-up?
- A. Sodium level
- B. Potassium level
- C. Blood Urea Nitrogen (BUN)
- D. Creatinine
Correct Answer: B
Rationale: Abnormal potassium levels can cause cardiac arrhythmias, a critical risk during surgery, requiring immediate follow-up. Sodium, BUN, and creatinine abnormalities are less immediately life-threatening but still important.
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The nurse is applying soft wrist restraints to a client who is violent towards the nursing staff. Which actions by the nurse are appropriate? Select all that apply.
- A. Places a pair of scissors at the bedside for emergent discontinuation.
- B. Positions the client supine after applying both wrist restraints.
- C. Releases both restraints at the same time, every two hours.
- D. Informs the client of the behavior necessary to demonstrate to end the restraints.
- E. Ensures two fingers can be placed under each restraint.
Correct Answer: D,E
Rationale: Informing the client of expected behavior and ensuring a two-finger gap promote safety and compliance. Scissors are unsafe, supine positioning is not required, and simultaneous release is impractical.
The nurse is having difficulty locating a vein, to start intravenous therapy, on a client who is dark-skinned. Which of these devices or procedures may be of benefit to you at this time?
- A. A doppler
- B. A surgical vein cut down
- C. A transillumination device
- D. A sonography
Correct Answer: C
Rationale: A transillumination device uses light to visualize veins, aiding IV insertion in clients with dark skin or poor vein visibility. Doppler assesses blood flow, surgical cutdown is invasive, and sonography is not typically used for peripheral IVs.
The nurse is caring for a client who has rubella. To prevent the spread of infection, which transmission-based precaution should the nurse implement?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: B
Rationale: Rubella requires droplet precautions due to respiratory transmission.
The nurse is educating the parents of a child who plans on riding their bicycle. Which statements, if made by the parents, indicate effective understanding?
- A. I should tell my child to ride their bike against the traffic pattern.
- B. I should instruct my child to walk their bike through busy intersection crosswalks.
- C. Wearing a helmet is only necessary when my child is riding near a busy intersection.
- D. My child can ride their bike barefoot as long as it's short distances.
Correct Answer: B
Rationale: Walking the bike through busy intersections enhances safety. Riding against traffic, optional helmet use, and barefoot riding are unsafe.
The following scenario applies to the next 1 items
The nurse cares for a client on the oncology floor
Item 1 of 1
Admission Note
Physician Orders
The client was admitted for observation after reporting increasing fatigue, dyspnea, malaise, and a fever of 102°F (38.8°C). The client is currently being treated with doxorubicin for uterine sarcoma. The initial diagnostic testing revealed pneumonia and neutropenia.
The nurse recognizes that this client is at increased risk for developing ………………… therefore, the nurse should implement neutropenic precautions which involves …………………. Considering the client has a fever, the nurse anticipates an order for ……………
- A. systemic infection
- B. chronic renal failure
- C. washing hands frequently.
- D. wearing sterile gloves for client care.
- E. performing frequent oral care.
- F. 24-hour urine collection.
- G. collecting blood cultures.
Correct Answer: A,C,G
Rationale: Neutropenia increases systemic infection risk, requiring frequent handwashing and blood cultures for fever evaluation.