Nokea
The nurse should tell a client who is scheduled for a bone marrow biopsy that the specimen can be withdrawn from which site?
- A. Ribs
- B. Femur
- C. Scapula
- D. Sternum
Correct Answer: D
Rationale: The most common sites for bone marrow biopsy in the adult are the iliac crest and the sternum. These areas are rich in bone marrow and are easily accessible for testing. The femur, scapula, and ribs are not sites for bone marrow biopsy.
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Which is an intrinsic risk factor that places the client at risk for pressure ulcers?
- A. Pressure
- B. Shearing
- C. Impaired tissue perfusion
- D. Friction
Correct Answer: C
Rationale: Impaired tissue perfusion is an intrinsic risk factor for pressure ulcers, as it reduces oxygen and nutrient delivery to tissues, increasing susceptibility to breakdown.
Which of the following is an essential component for insuring that medical equipment is being used safely and properly by those who you supervise?
- A. Education and training on all pieces of equipment
- B. Pilot testing new equipment
- C. Reading all the manufacturer's instructions
- D. Researching the equipment before recommending its purchase
Correct Answer: A
Rationale: Education and training on all pieces of equipment is essential to ensure staff can use equipment safely and correctly, reducing risks to clients and staff.
A newborn infant is diagnosed with imperforate anus. Which description of this disorder should the nurse provide to the parents?
- A. The presence of fecal incontinence
- B. Incomplete development of the anus
- C. The infrequent and difficult passage of dry stools
- D. Invagination of a section of the intestine into the distal bowel
Correct Answer: B
Rationale: Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Option 1 describes encopresis. Encopresis generally affects preschool and school-age children. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at age 2 to 3 years. Option 4 describes intussusception.
A client with type 1 diabetes mellitus is admitted with hyperglycemia. The nurse administers regular insulin as ordered. When should the nurse expect the insulin to begin acting?
- A. 15 to 30 minutes
- B. 1 to 2 hours
- C. 2 to 4 hours
- D. 4 to 6 hours
Correct Answer: A
Rationale: Regular insulin, a short-acting insulin, typically begins acting within 15 to 30 minutes after subcutaneous administration, making it effective for rapid blood glucose control.
The nurse is caring for a postoperative client who reports a pain level of 8 out of 10. The client has an order for morphine 4 mg IV every 4 hours as needed. What is the nurse's priority action?
- A. Administer the morphine as ordered.
- B. Assess the client's vital signs and pain characteristics.
- C. Apply a warm compress to the surgical site.
- D. Encourage the client to use distraction techniques.
Correct Answer: B
Rationale: Assessing vital signs and pain characteristics ensures the pain is accurately evaluated and the morphine is safe to administer, considering potential side effects like respiratory depression.