Nokea
The nurse is supervising care given to clients on a medical/surgical unit.
The nurse should intervene if which of the following is observed?
- A. A nurse and client wear masks during a dressing change for the central catheter used for total parenteral nutrition.
- B. A nurse injects insulin through a single-lumen percutaneous central catheter for client receiving total parenteral nutrition.
- C. A nurse applies lip balm to his/her lips immediately after performing a blood draw to obtain a specimen.
- D. A nurse wears a disposable particulate respirator when administering rifampin to a client with tuberculosis.
Correct Answer: C
Rationale: Strategy: 'Nurse should intervene' indicates that you are looking for an incorrect action. (1) appropriate procedure, prevents airborne contamination (2) insulin is the only medication that can be given, compatible with TPN (3) correct-applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur (4) use airborne precautions for TB, private room with negative air pressure, minimum of six exchanges per hour
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A client with a gastric ulcer is losing a significant amount of blood via the NG tube. The client's pulse is weak and thready, and she is hypotensive. A continuous irrigation of normal saline is ordered. How should the client be positioned?
- A. High Fowler's
- B. Semi-Fowler's
- C. Supine
- D. Left-side lying
Correct Answer: B
Rationale: Semi-Fowler's position helps prevent aspiration and facilitates gastric drainage in a hypotensive client with gastric bleeding.
Which of the following statements describes Piaget's stage of concrete operations?
- A. Reflex activity proceeds to imitative behavior.
- B. There is an increased ability to see another's point of view.
- C. Thought processes become more logical and coherent.
- D. The ability to think abstractly leads to logical conclusions.
Correct Answer: C
Rationale: Concrete operations (ages 7-11) involve logical, coherent thought about concrete events. Perspective-taking develops but is not primary, and abstract thinking is characteristic of later stages.
The nurse is caring for a client who is postoperative day 1 after a total knee replacement. Which of the following actions should the nurse prioritize?
- A. Encourage use of the incentive spirometer.
- B. Administer pain medication as needed.
- C. Apply a continuous passive motion (CPM) machine.
- D. Check the surgical dressing for drainage.
Correct Answer: C
Rationale: Applying the CPM machine prevents stiffness and promotes mobility post-knee replacement. Options A, B, and D are secondary.
The doctor has ordered chlorpromazine (Thorazine) to control an alcoholic client's restlessness, agitation, and irritability following surgery. The nurse should check the order with the doctor based on which of the following rationales?
- A. The nurse believes that the client's symptoms reflect alcohol withdrawal.
- B. The nurse does not know if the client is allergic to this medication.
- C. The nurse knows that the client is not psychotic.
- D. The nurse routinely checks on the doctor's orders.
Correct Answer: A
Rationale: medication is contraindicated for the treatment of alcohol withdrawal symptoms; medication will lower client's seizure threshold and BP, causing potentially serious medical consequences
The nurse knows that the client with peripheral vascular disease understands her instructions in ways to improve circulation if the client states
- A. I will massage my legs three times a day.
- B. I will elevate the foot of my bed on blocks.
- C. I will take a brisk walk for 20 minutes each day.
- D. I will prop my feet up when I sit to watch TV.
Correct Answer: C
Rationale: Answer C is the 'odd answer' and correct. Walking improves circulation by developing muscles that support blood vessels. Massaging may dislodge clots, elevating the bed is not specific to circulation, and propping feet reduces venous pooling but is less effective than walking.